Louise Howe, Advanced Practitioner of Occupational Therapy and Simon Hammond, Clinical Nurse Specialist for Dementia and Sarah Goldberg, Trial Manager, Nottingham University Hospitals NHS Trust

Background

A specialist Medical and Mental Health Unit (MMHU) has been developed at Nottingham University Hospital for older people admitted to the hospital as a medical emergency who are also ‘confused’ (mostly dementia and/or delirium). It is being evaluated by randomised controlled trial as part of a National Institute for Health Research (NIHR) programme grant - 'Medical Crises in Older People'.

The model of care was shaped by professional opinion, literature review, the findings of an observational and interview study (Gladman et al 2012), and emerging practical experience and around the philosophies of comprehensive geriatric assessment and person-centred dementia care.

Aims

To improve the quality of care to patients admitted to our hospital as a medical emergency who also had dementia and/or delirium.

What did you do?

Additional Staffing

The ward staffing and skill mix was enhanced with mental health trained nurses, doctors and allied health professionals. Healthcare assistants were recruited to act as activity co-ordinators.

Person-centred care

Ward staff were trained in Kitwood’s model of person-centred care (Kitwood 1997) through time out days, ward based training and role modelling. A personal profile document ‘About me’ was developed to gain information about the patient, their life story, likes and dislikes, routine, and how to support them when they are distressed.

Organised activity

The activity coordinators, under the supervision of the senior occupational therapist, carried out a programme of individual and group work aimed at maintaining and regaining physical, cognitive and social skills as well as reducing anxiety and associated behaviours. Activities included a breakfast club, physical activities, reminiscence, music and craft activities.

Environmental

The ward bay areas were decorated different colours to individualise them. Orientation boards, improved signage and large anti-glare clocks were put up in each bay and side room, and the ward was made more visually attractive with pictures on the walls. Sofas, tables and chairs were put at the end of the bays to offer patients different places to sit and socialise. Entrance to clinical rooms was restricted by combination locks, equipment such as fire extinguishers were boxed away.

Carer involvement

Leaflets were produced on topics such as the dementia, delirium, person-centred care, discharge arrangements and end of life care. Documents entitled ‘About me’ and ‘Caring together’ were developed to engage carers and provide further information to assist. Visiting hours were made flexible, family carers were encouraged to help with hands on care where they wanted to and the Alzheimer’s Society provided regular input with carers on the ward.

What changed?

The MMHU has won a National Health and Social Care Award for Mental Health and Wellbeing. The MMHU has also been visited by MPs and the National Clinical Director for Dementia. The development of the MMHU has been a focal point of expertise and skill for the hospital to use in the development of their response to the National Dementia Strategy.

The links between the ward and mental health services have been strengthened and this allows for more collaborative working. The sharing of information across the Trusts has been vital in the management of patients with complex needs. This has enabled links with mental health services on discharge to support the patients and carers in the community.

The unit is currently being evaluated by randomised controlled trial with a primary outcome measure of 90 day days at home (days the patient isn’t in hospital, hasn’t been admitted to a care home, or changed care home, isn’t dead) and a range of other 90 day health status measurements. The evaluation also involves: an economic evaluation; a structured observational study of patients sub-sampled from the main trial (using the Dementia Care Mapping tool); carer, patient and staff interview study. Results will be available soon.

We have done some service evaluation….

The activity programme evaluated well especially the breakfast group where an increase in nutritional intake was observed. Further evaluation is being carried out with data gained from the observational study.

Advice for others

It is possible to improve the quality of hospital care for older people with dementia and/or delirium. It requires the integration of mental health services with acute medical services, enhanced staffing numbers, organised activity and a person-centred care approach adapted to the needs of patients in hospital, along with a proactive and supportive approach to family carers.

The Medical Crises in Older People discussion paper five provides more information on the development of the ward see Development of a specialist medical and mental health unit for older people in an acute general hospital (PDF 482.7KB) [see how to access PDF files].

See also a related article published in the Daily Mail on 12 February 2013 about the care given to people with dementia in Ward B47, Nottingham University Hospital at Inside the hospital that's leading a kindness revolution.