improving care for inpatients with dementia at the royal berks · improving care for inpatients...
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Improving care for inpatients with dementia at the Royal Berks
Professor David Oliver. Consultant Geriatrician, Royal Berkshire NHS Foundation Trust
Dr Luke Solomons. Consultant Psychiatrist, Berkshire Healthcare Trust
10/10/2012
Dementia Seminar
What is dementia?
− “The term 'dementia' describes a set of symptoms which include loss of memory, mood changes, and problems with communication and reasoning. These symptoms occur when the brain is damaged by certain diseases, including Alzheimer's disease and damage caused by a series of small strokes.”
(www.alzheimer’s.org.uk)
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Dementia Seminar
− “Dementia is progressive, which means the symptoms will gradually get worse. How fast dementia progresses will depend on the individual person and what type of dementia they have. Each person is unique and will experience dementia in their own way. It is often the case that the person's family and friends are more concerned about the symptoms than the person may be themselves.”
www.alzheimer’s.org.uk
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Dementia Seminar
How does dementia affect people?
− “Loss of memory” − this particularly affects short-term memory, for example forgetting what happened earlier in the day, not being able to recall conversations, being repetitive or forgetting the way home from the shops. Long-term memory is usually still quite good.”
− “Mood changes” − people with dementia may be withdrawn, sad, frightened or angryabout what is happening to them.”
− “Communication problems” − including problems finding the right words for things, for example describing the function of an item instead of naming it.”
− “In the later stages of dementia, the person affected will have problems carrying outeveryday tasks and will become increasingly dependent on other people.”
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Dementia Seminar
Screening for Dementia e.g.− Six item test of cognitive function (6CIT):− 1. What year is it? − 2. What month is it? − 3. Give the patient an address phrase to remember with 5 components,
e.g. John Smith, 42, High St, Bedford − 4. About what time is it (within 1 hour) − 5. Count backwards from 20-1 − 6. Say the months of the year in reverse Repeat address phrase
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Dementia Seminar
Diagnosing Dementia
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Dementia Seminar
Differential diagnoses− Not all dementia is “Alzheimer’s” (c55%)
– Also “vascular” (c25%), mixed, and rarer forms (e.g. Lewy Body disease, Huntington’s etc)
− Many older people with memory problems only have “mild cognitive impairment” –this increases the risk of dementia
− Other conditions can cause similar symptoms so need to be ruled out or treated
– “Delirium” or “acute confusion” (very common in older people admitted to hospital and often reversible)
– Depression causing “pseudo-dementia”
– Metabolic problems (e.g. thyroid, thiamine deficiency)
– Brain tumours or bleeding
II: The scale of the challenge
And implications for hospitals
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Dementia Seminar
c. 670,000 with Dementia in England, set to double in 30 years
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Dementia Seminar
National Policy and Action− National Dementia Strategy (last government and this)− Dementia Action Alliance and Declaration (over 50 organisations)− RCN Dementia in Hospitals Project− Prime Minister’s Dementia Challenge− NHS Operating Framework− New Health Ministers committed− Dementia CQUIN payment for patients admitted to general hospitals− NICE Dementia Guidelines− Mental Capacity Act− NHS Constitution and Equality Act
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Dementia Seminar
Dementia affects c 750,000 People in the UK – expected to double within the next 20 years
Alzheimer’s Disease International, 2009
[Total NHS spend in England £122bn.
[Total spend on Dementia in Health and Social Care £8.2bn]
[Total spend on police and prisons £9.4bn]
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Dementia Seminar
Nursing and Residential Homes(BGS Quest for Quality Report 2011)
− c. 380,000 residents (England)− Average age 86− 78% have one form of cognitive impairment− 64 % “confused or forgetful”− 20% “challenging behaviour”− 20% “depressed or anxious”− 27% immobile, confused and incontinent
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Dementia Seminar
10/10/2012
Dementia Seminar
ONS Projections (146% increase in over 90s & 85% in over 80s in next 20 years)
Population 000
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Dementia Seminar
Over 65s in hospital (England)(DH analysis of HES data)
− 60% admissions
− 70% bed days
− 85% delayed transfers
− 65% emergency readmissions
− 75% deaths in hospital
− 25% bed days are in over 85s
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Dementia Seminar
“Who cares wins” 2005 c. 1 in 4 adult beds occupied by someone with Dementia (usually admitted for other reasons)
− Typical 500 bed DGH
− 5000 admissions over 65 each year
− 3000 with mental disorder
− On snapshot
– 220 beds – mental disorder in over 65s
– 96 depression
– 102 dementia– 66 delirium
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Dementia Seminar
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Dementia Seminar
Counting the Cost
− 1 in 4 adult beds is occupied by someone with dementia
− People with dementia stay longer
− The longer they stay in hospital the worse the effect on the symptoms of dementia and physical health, more likely to lose function, be discharged to a care home or be prescribed antipsychotics
− “Much of the large sums of money spent on dementia care in general hospitals could be more effectively invested in workforce capacity and development and in community services outside hospitals to drive up the quality of care on the wards improve efficiency and ensure that people with dementia only access acute care when appropriate”
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Dementia Seminar
Key Questions for Trust Boards (“Acute Awareness”)
III: How well are we doing these things in the NHS?
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Dementia Seminar
General issues in inpatient care of older people (many have dementia)
− Numerous reports on undignified care– Ombudsman, CQC, Patients’ Association CARE Campaign, All Parliamentary
Enquiry. “Delivering Dignity” commission− Safety
– e.g. falls, pressure sores, infections, discharge/readmission, drug errors− Data from major audits
– Falls, fractures, hip fracture, nutrition, continence, periop care− Evidence of age-based discrimination
– e.g. Centre for policy on ageing reviews− Inefficiency and “unwarranted variation”
– e.g. delayed transfers of care, emergency readmission, chance of admission, hospital bed days in over 65s
− Francis Report
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Dementia Seminar
Counting the Cost Report
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Dementia Seminar
“Counting the Cost”, 1,291 carers, 657 nurses, 479 ward managers
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Dementia Seminar
− Care planning and support in relation to the dementia (i.e. not just the acute condition) from admission to discharge
− Care of patients with acute confusion− Maintaining dignity in care− Maintenance of patient ability− Communication and collaboration: staff and patients/ carers− Information exchange− End-of-life care− Ward environment
RCPsych Audit. What were patient/carer priorities?
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Dementia Seminar
RCPsych Audit 2010 of acute trusts
− Only 30% had system for gathering personal information on person with dementia
− 70% had no review process for discharge procedures on people with dementia
− 77% of had no training strategy identifying key skills for working with people with dementia
− 95% of had no mandatory awareness training− 81% of had no system to ensure ward staff were aware that a person had
dementia and that necessary information was imparted to other staff
− 90% had some access to liaison psychiatry but 36% patients not seen after 96 hours and only 40% within 48 hours
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Dementia Seminar
From RCPysch Audit review of casenotes of 7,934 patients 2010− 41% received standard mental test score while in hospital
− 90% of hospitals had some access to liaison psychiatry but only 40% seen in 48 hours and 36% not seen after 96 hours of referral
− 26% of hospitals documented assessment of carers needs in advance on discharge
− 30% of patients had no documentation of nutritional status
IV: Local response: Our integrated dementia steering group
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Dementia Seminar
Integrated dementia steering group− Late 2009. D.O. = lead clinician
− Driven “bottom up” by local enthusiasts
− Didn’t wait to be told from on high
− Purpose (always evolving):
– One space for all parties with a stake
– Networking, social capital, momentum, sharing of resources
– Develop education, training and skills
– Improve care (both personal/essential and technical/diagnostic)
– Involve carers/patients more
– Improve environment for care
− And renew the previous push for commissioning an older peoples mental health liaison team… (OPMHLT)
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Dementia Seminar
Dementia Steering Group
CARE HOMES
GPs &DIST. NURSES
COMM. MENTALHEALTH
THERAPIES
CARERS
LOCAL AUTHORITY
PATIENTS
INTERMEDIATECARE
ALZ. SOC.AGE UK
RED CROSS
CCGsPUBLIC HEALTH
EoLC
MEMORYCLINIC
V: Local response: Older Peoples Mental Health Liaison Team
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Dementia Seminar
Service Description
− The Royal Berkshire Hospital has 813 beds
− The Liaison team was set up according to PLAN (Psych. Liaison Accreditation Network) standards and comprises:
– 0.5 Consultant Psychiatrist
– 1.0 Band 7 nurse/ Team Leader
– 2.0 Band 6 nurses (dual trained mental & physical health nurses)
– 1.0 Social worker
– 0.5 Speech and Language therapist
– 1.0 Medical secretary/administrator
– 0.2 Clinical psychologist
– 0.2 Consultant Geriatrician (not yet started)
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Dementia Seminar
Governance Umbrellas
Berkshire Healthcare FT (Mental Health)
Adult Directorate
Royal Berkshire FT (acute care)
Networked Care Directorate LIAISONPSYCH
SERVICE
• Clinical Audit/ governance
• Incident reporting
• Complaints/ compliments
• Future planning
• Research
DEMENTIA STEERING GROUP
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Dementia Seminar
Prevention/ Training Acute Rehab/
End of Life Care
Prevention Awareness InitialAssessment
On-goingAssessment
Care Transition Outreach
Care
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Dementia Seminar
Admission Checklist (on CDU as well):Bedman flag“Info About Me” completionEnsure GP / collateral history obtainedVisible bed / orientation cuesLow stimulation / low noisePersonal belongings (dentures / glasses)Liaison Psychiatry
Dementia Care Plan:BPSD bundle DietCommunication EliminationExercise SafeguardingMCA
Ward Discharge Plan:OT/PT involvementSection 2 Social ServicesCarer’s assessmentMDT care planDischarge letter – Memory clinic F/U
- Stop antipsychotic if started
Ensure Memory Clinic Follow-up:Ask GP to refer to Memory ClinicCare PackageDelirium prevention adviceDementia leaflet
A&EScreen ALL Patients for memory problems
(FAIR – dementia CQUIN)
CDU WARDS
Discharge Home
VI: Benefits we are starting to see
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Dementia Seminar
Benefits: steering group− Public Engagement− Dementia themed trust members meeting− Dementia awareness week− Patient documents: “This is me”
“Forget-me –not”− Care Bundle for Behavioural and Psychological Symptoms− Learning from dementia-related complaints and safety incidents being built into
governance− Good performance on RCPsych Dementia Audit (e.g. able to answer “yes” to 38 of 41
organisational questions)
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Dementia Seminar
Referral numbers to OPMHLTYear 2011 2012 Total
658
M
O
N
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
NO. 37 39 43 38 44 48 50 63 69 85 69 73
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Dementia Seminar
Diagnoses - 2011
Alzheimers dementia
16%
Vascular dementia
26%
other dementia7%
Delirium resolved
7%
MCI9%
Functional illness33%
No mental illness
2%
Alzheimers dementiaVascular dementiaother dementiaDelirium resolvedMCIFunctional illnessNo mental illness
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Dementia Seminar
Response times
− 2011− 100% of all routine referrals seen in 48 hrs
− 99.4% of all urgent referrals seen in 24 hrs
− 100% of all emergencies seen within 4 hrs
• 2011 - Patient safety incidents involving confused older patients fell from 142 to 53
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Dementia Seminar
Quality – patient feedbackNo. answering yes/ agreeing %
N = 09 (able to fill in feedback)
Did ward staff take permission to refer 4/9 44%
Were you informed why you were being referred to liaison psych? 7/9 77%
Were OPMHLT attentive to you? 8/9 88%
Did they explain the diagnosis? 8/9 88%
Did you feel safe/ comfortable during asseessment? 8/9 88%
OPMHLT improved quality of care 8/9 88%
Would you recommend OPMHLT? 9/9 100%
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Dementia Seminar
Quality/ SatisfactionNo. answering yes %
N= 19 (7 doctors, 5 nurses, 5 AHP)
Aware of OPMHLT 14/18 78%
Guidance on eligibility 15/18 79%
Easy referral? 16/17 94%
Appropriate OPMHLT response 17/18 94%
OPMHLT helpful/informative? 19/19 100%
OPMHLT improved quality of care 18/18 100%
OPMHLT knowledeable 18/18 100%
OPMHLT flexible 19/19 100%
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Dementia Seminar
Training− Training delivered with RBH practice educators and matrons
− > 700 staff now through dementia training
− 40 dementia champions across RBH, receiving full training over 6 months (in-house training saved trust £30,000)
− Security staff and porters trained up
− Intend to offer training package to SHA
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Dementia Seminar
Training
− Large Group
− Teaching for FYs
− Teaching at large groups – Tues pm elderly care updates
− Grand rounds
− DEMENTIA CHAMPIONS
− Ward Based
− Cover all hospital wards
− Informal teaching at hand over time
− Topics chosen by ward staff
− Bedside, hands on training for staff
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Dementia Seminar
Dementia Champions -
− Bottom up approach
− Aim is to have ALL staff dementia competent
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Dementia Seminar
Care extends beyond RBH…− Links to intermediate care, community mental health teams and
community geriatricians (psychogeriatrician and geriatricians work across sites and link to primary care)
− Example – Reducing inappropriate antipsychotic use. All NH audited by geriatrician, agreement with primary care to stop in 6 weeks.
VI: Where would we like to go next?
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Dementia Seminar
Future?
− Keep on training till everyone trained, then do it again!
− Expanding the role of dementia champions
− Implementing the dementia CQUIN
− Round 2 of RCPsych audit and identify gaps for action
− More focus on discharge planning and communication
− More learning from complaints and incidents
− More use of patient/carer stories in training
− Expansion of OPMHLT
− More improvement of environment for care
− Joint memory clinics
− Economic impact?
