Colin MacDonald, Alzheimer Scotland Nurse, Royal Infirmary of Edinburgh

Background

This work took place in an acute general hospital, the Royal Infirmary of Edinburgh.

Concerns about the care and treatment of people with dementia in the acute general hospital have been well documented. Recent reports such as 'Counting the cost' (Alzheimer’s Society 2009) have highlighted poor outcomes for people with dementia, including:

• reduced physical abilities
• increased disturbance in patterns of behaviour
• longer length of stay
• more likely to be prescribed psychoactive medications
• > 30 per cent risk of being discharged to a care home.

With an estimated 20 per cent of beds occupied by people with dementia in an average general hospital, and demographic predictions that the number of people with dementia is likely to double in the next 25 years, it is clear that we need to look at how we can do things differently.

As one of the first Alzheimer Scotland nurse consultants, one of my key objectives was to improve the care and support of people with dementia in the general hospital and to demonstrate better outcomes.

Aims

Improved outcomes related to reduced processes of care that can contribute towards delirium and a disabling impact on the person with dementia, as well as improved experiences for both the person and their carer:

• reduced length of stay
• reduced moves
• reduction in use of:
- psychoactive medications
- catheters
• reduced discharge to long term care setting (e.g. care home)
• person with dementia and carer survey
• staff survey.

What did you do?

I focused a particular model of support on five wards, with a view to setting them up as ‘beacon wards’ of good practice.

Six wards were initially identified from one acute general hospital system. They were identified using the following criteria:

• self referral
• areas of concern
• highest throughput of patients with dementia.

Wards selected included:

• combined assessment unit (admission/assessment)
• stroke ward
• older people assessment ward
• orthopaedic ward
• rehab / assessment ward.

My model of support focused on the following areas:

• regular (visible) support (including working alongside staff)
• education sessions
• education and information resources
• environmental audit and adaptations
• C/N’s ‘signing up’ to 10 good practice statements (as measurements of achievement).

What changed?

• Reduced moves and length of stay.
• Reduction in discharges to long term care.
• Reduction in use of psychoactive medication.
• Reduction in use of catheters.
• Improved satisfaction rates by carers.
• Improved confidence and well being amongst staff.

This audit project was only a small ‘snapshot’ of a general hospital system, and any results indicated should be taken into this context.

But it does demonstrate positive trends that can be achieved...

Advice for others

I am convinced that most nurses do not come to the work to do a bad job. It is therefore imperative that we understand not only their lack of understanding of dementia, but also the organisational and culture influences that will impact on them.

My knowledge and understanding of ward cultures helped significantly in this respect, and how I tried to influence nursing staff. Important factors included:

• the variety of clinical pressures and expectations of nurses
• the clinical environment
• the importance and influence of the ward C/N
• not adding to staff work or documentation
• keeping things simple - and easy to achieve
• demonstrating skills and advice - by being prepared to work alongside staff
• feeding back on achievements - allowing nursing staff an opportunity to see and celebrate any successes!