Karen Bowley, Matron Care of Older People, Royal Wolverhampton Hospitals NHS Trust

Background

Royal Wolverhampton Hospitals NHS Trust was commissioned to undertake a programme of work to develop a person-centred model of care for people with dementia in acute hospitals, with a dementia care bundle at its heart. A care bundle is a methodology for improving outcomes. It is an evidence-based set of interventions which are delivered consistently (optimal 95 per cent) and regularly according to the needs and care plans of individuals.  

This work was in direct response to the National Dementia Strategy published in 2009 which highlighted poor practice and outcomes for patients in acute hospitals and stated that improvement was necessary but did not specify how this might be achieved.

New Cross Hospital is an acute hospital, which has 650-700 beds and employs approximately 5000 staff.  

Aim

The aims were:

• to create a ‘dementia friendly’ hospital which is sensitive to the disabling impact of dementia and which minimises the impact of disorientation of people with dementia using the hospital
• to provide evidence-based high standards of care
• to improve the clinical outcomes of patients with dementia
• to reduce the number of people discharged from hospital newly into residential and nursing homes for long-term care
• to provide cost effective care.

The evaluation study undertook the following methodology to assess and measure success against the above.

• Conducting interviews and surveys of the opinions of families and staff before and after introduction of the new services.
• Observing and reviewing consistency in application of care bundle.
• Reviewing the summary of complaints and compliments received before and after the services commenced.
• Using the local findings of the National Dementia Audit.  
• Reviewing hospital data to monitor performance against the above aims.
• Undertaking a cost benefit analysis of the new services.
• Reviewing methodology adopted in the programme of work.

What did you do?

The following is a list of activities undertaken with the work programme to ensure a composite approach to service improvement to those with dementia at New Cross Hospital.

• Established project structure and workstreams to ensure a composite approach to service improvement. The Trust Chief Executive chaired the steering group involving Director of Commissioning, Local Authority Head of Adult Services, SHA Service Lead  as well as clinical representatives. The Director Lead was identified, Project Manager appointed, Project team including clinical leads and carer representation identified.
• Undertook a literature search to identify evidence and good practice.
• Involved clinicians to agree clinical model within the hospital - decision made to proceed with dedicated ward supported by multidisciplinary outreach team within the hospital to create a dementia friendly hospital. Role of Liaison Psychiatry team in relation to Acute hospital dementia services agreed.
• Methodology developed using point prevalence studies for identifying patients throughout hospital along with introduction of flagging system for people with dementia using hospital services.
• Set up reference group, involving representatives of community groups from across Wolverhampton, to ensure diversity and equality of service provision and to contribute to development of services.
• External evaluation process established led by Professor Upton at Worcester University.
• Acute Medical ward for people with complex range of diagnoses including dementia redesigned and refurbished using Kings Fund ‘Enhancing Healing Environment’ principles. Facilities include 20 beds involving four single sex bays of five beds each which all include two individual rooms and nurse desk, multipurpose day rooms for dining and activities, garden, and overnight ensuite facilities for relatives/carers.
• Ward staff team and hospital outreach team recruited.
• Training and skills development programme established providing a hierarchical range of skills development and awareness raising. The intention is to ensure all staff have a basic level of awareness. Induction programmes include dementia awareness session and all nurses receive a more indepth level of training. The training is a mixture of classroom modules and ward based training and is being developed using different media including e-learning. The training is targeted at staff groups with specific key roles eg security and portering.
• Operational processes and policies developed to facilitate the development of person-centred care, for example catering services adapted to provide more flexible catering services.
• Clinical staff and carer representative developed person-centred care planning processes using adapted ‘About me‘ documentation. Professor Dawn Brooker, Association for Dementia Studies advised and supported the development of services.
• Care bundle developed and tested with support and advice from Dr Roger Resar, IHI in Boston, USA.
• Outreach team operational policies and processes agreed and proactive and reactive services introduced and rolled out across the hospital.
• Use of care bundle being tested and developed in other ward areas.
• Discharge processes being reviewed and adapted. Dedicated social worker identified.
• Project work to review and adapt Out Patient and Accident and Emergency  services to provide services which are more responsive to needs of those with dementia.
• Use of technology in care processes reviewed and continue to be introduced.
• Set of metrics and KPIs introduced to monitor performance developed.
• Learning from work programme to be shared with hospitals in West Midlands.

What changed?

The successes of the work programme to date are as follows:

• there has been a reduction in the number of falls and injury from falls and also hospital acquired chest and urinary tract infections
• there has been a very significant increase in the number of patients discharged  to their admission address
• there is a high level of satisfaction amongst staff as measured by very low sickness absence levels and turnover levels and staff approval ratings
• there is a high rate of satisfaction among patients and families and there have been no complaints about the services provided on the dedicated ward and many compliments and letters of appreciation
• it is estimated that if the rate of discharge back to admission address continues at the current level there will be significant savings to the health and social care system of care
• so far there has been no reduction in length of stay, which was an expected outcome. However work is underway currently to review the discharge process in order to address this
• the pace of change has not been as swift as hoped mainly due to delays in recruitment of the outreach team and the introduction of the service in the wider hospital. However it is now progressing well.

Advice for others

The Trust believes this is a sustainable service mainly because of the culture change and improvement in clinical practice which is underway within the hospital. Leadership provided by the Chief Executive and Director of Nursing and Midwifery   and the priority which has been afforded to this work within the Trust is a key success factor which cannot be understated.

The change in practice and improved standards of care relate to basic nursing practice which the trust believes can be adopted and transferred into other settings such as community hospitals and indeed nursing homes.

Capital costs from the Trust capital programme were involved in the upgrading and redesign of the ward and other patient areas although the design features are now included in future ward developments.

The Commissioners have funded the new service on a pilot basis: the number of beds available on the redesigned ward was reduced by eight; staffing levels were enhanced; the skill level adjusted to take account of the higher concentration of frailty and the particular needs of people with dementia.

The outreach service is a newly funded service and the continuation will depend upon continuing success in clinical and other outcomes for patients.

The final evaluation report is due for publication in January 2012 and this will set out an analysis of benefits and costs.

For further information please contact Karen Bowley at karen.bowley@nhs.net

See other examples at Dementia - best practice examples.