Transforming Dementia Care within Royal Cornwall

Hospital Trusts

Dr Fiona Boyd, Dementia Lead.

Bev Chapman, PCT Lead

Maggie Trevethan, Clinical Nurse Lead

Past ,Present and Future Service development to date Ongoing projects Our vision

To date. Ongoing over 5 years Shared care philosophy Designated clinical lead Designated ward base Collaborative working

Long Term Condition Diagnosis Maintenance Complex Palliative

Dementia Mapping - Comparison figures 2006-2008

Bed base 588 nTD = 69 (11%) nDementia=57(10%) nDelerium=9(1%)

Bed base 538 nTD=74(13%) nDementia=57(10%) nDelerium=17(3%)

Correlation between delay in discharge and those patients with cognitive impairment

A direct positive correlation between delay in discharge and those patients with cognitive impairment who demonstrated evidence of disability. 2008

Correlation Between Delay in Discharge and the Presence of Disability.

y = 0.8333x

R2 = 0.7143

0

0.25

0.5

0.75

1

1.25

0 0.25 0.5 0.75 1 1.25

Disability

Delayed Discharge

66% of these patients are located within the Medical Directorate.

45% of all cognitively impaired patients in RCHT Eldercare setting

30% individuals - ‘bed-blocking’ whilst they awaited discharge from hospital to care home environments.

The RCHT Memory Service provides Diagnosis (with a front door service) Rapid access to investigations and

assessments Designated ward with specialty trained staff Guidelines and Care Pathways Supervision & reduction in

prescribing(sedation &antipsychotics) Patient and Carer support Improved Awareness and Education

Guidelines and PathwaysGuidelines Dementia Acute Confusion Palliative Care Pain management Mental Capacity Anti-psychotic

prescribing DOLS

Pathways and other Behavioural Chart and

assessment tools Cognitive assessment

tools PAINAD Carers support Life story books Communication Alert

scheme

Education and Awareness Local to RCHT:

Training F1/2, GP AND Specialty registrars trainees

PMS Mental Capacity DOLS ‘Lets respect’ -DoH Competency Training for Nursing staff and allied

specialties Patient and Carers forum

Education and Awareness Regional:

Annual Eldercare Good Practice Day 2004-07 Dementia Away Day 2006 Lets Respect RCH(CIPS-Plymouth 2007) Hospice Staff training 2008/09 Gp training day 2008/09 Community Matrons 2008/09 Dementia Academy 2009 Worried About Your Memory (Alzheimers Society

2008-9) BBC Radio Cornwall Phone-in (2008/09)

Education and Awareness National:

RCN: The Journey End –approach to palliative care (Cardiff 2007)

RCN :Lets Respect –Communication Alert System( Edinburgh 2009)

National Palliative Care Conference (7th): Palliative care in Dementia (Glasgow 2008)

Psychiatry & Mental Health –Communication Alert Scheme (Leeds 2009)

RCN: –Communication Alert Scheme–(Edinburgh 2009)

OPMHG -Cornwall Participation in Developing Cornwall

Strategy Regional Audit

Other Related Activities

Joint PCT/RCHT Audit of Nursing Home Admissions

Dr Fiona Boyd

Bev Chapman

Kylie Cook

Maggie Trevethan

Aims

Retrospective Audit Admissions involving NH Identify the appropriateness of the admission with a view to developing pathways to reduce admissions and facilitate more effective patient journey

Reference details: Audit number NHS Number: Care home: Sex Age Time of admission  DOA DOD LOS  Referral source: GP/ A& E SB GP yes/no Ward allocation(s): 1

234

 Reason for admission: Diagnosis (es) 1

234

  Prescribing issues: Yes /NoIf yes, comment:  Nursing needs: Yes/No If yes: date of request date actioned Review date Delaying factors  Place of discharge  Possible alternatives to admission 

Provisional Data Jan-March 2009 Total Number Admissions 91 Length of Stay 1421 bed days See by GP before admission 27 (30%)

Required admission 10 (37% of reviews; n/11% )

Seen ‘Out of Hours’ 59%

Breakdown of Admission Types

Reasons for Admission to RCHT.

27%

12%

9%

8%

8%6%

30%

Infection Cardiac Falls (no

fracture) Stroke Fractures

Not Eating Other

‘Other’

General breathlessness

– fatigue/exhaustion/SOB (12%) Admission from CPT Step up care (4%)

Other important Findings Palliative 29 (32%) Treatment feasible in the Home 64 (70%)

What’s Next? Analyse all data and correlate results Clear patterns:

End of Life Care

Appropriateness of Admissions

Links with Advanced Planning for End of Life Care & review of community care

Guidelines: Dementia Section 1 Dementia Pathway Summary Section 2 What To Do on Admission and Why. Section 3 How to Manage Difficult Behaviours. Section 4 Dementia Assessment Tools and Care Plans Section 5 Discharge Planning and Who To Contact. Section 6 Assessing Capacity. Section 7 Contact List of Community Mental Health

Teams Section 8 Appendices of Assessment Tools and Care

Plans

No

Cognitive deficit identified: Chronic / Acute on Chronic / Acute

Suspected Dementia

History

Examination

Investigations

Cognitive Assessment

Identify and Treat reversible factors

Contact Eldercare team for definite diagnosis

Diagnosis Dementia Known

Check who made diagnosis and date

No Psychiatric input needed discharge as per medical needs

Is deterioration rapid and unexplained?

Does history include:Deteriorating cognitionChallenging behaviourComplex discharge

Yes

No

Yes

Nurse in a Calm Quiet Environment

Any psychiatric concerns?Risk to others / self?

No

Contact eldercare psychiatric liaison team via switchboardIf unavailable contact on call mental health services on ext 1300Consider using section 5(2) Mental Health Act if necessaryUsing monitoring tools (see section 4) and sedate as necessary

Use sedation if necessary. Adjust dose according to body mass and renal function. Review daily. Only if severe distress or there is an immediate risk of harm to the person with dementia or to others.

Yes

For details of above flow chart see following page

24 hour behavioural chart

Time 24hrs

Agitation/Restlessness

Violence/Aggression

Care Refusal

Wandering

Fall

Pain

Sleep Disturbance

Settled

Guidelines : Pain > 50% of elderly suffer from painful

conditions Pain control is frequently inadequate. Demographic shift –increase in elderly

population The number of patients with

dementia who will experience pain is likely to increase.

Patients with Dementia

Experience communication difficulties Lack understanding Interpret and express their pain in ways

PAINADItems* 0 1 2 S

core

Breathing independent of vocalization

Normal Occasional laboured breathing. Short period of hyperventilation.

Noisy laboured breathing. Long period of hyperventilation. Cheyne-Stokes respirations.

Negative vocalization

None Occasional moan or groan. Low-level speech with a negative or disapproving quality.

Repeated troubled calling out. Loud moaning or groaning. Crying.

Facial expression

Smiling or inexpressive

Sad. Frightened. Frown. Facial grimacing.

Body language Relaxed Tense. Distressed pacing. Fidgeting.

Rigid. Fists clenched. Knees pulled up. Pulling or pushing away. Striking out.

Consolability No need to console

Distracted or reassured by voice or touch.

Unable to console, distract or reassure.

Total**

Guidelines: Palliative Understand the drivers to improving end of

life care for those with dementia

Identifying terminal phase care

Practical measures (care pathways)

Key Aims: Determining whether someone is ‘end

stage’ – using clinical diagnostic indicators and specialist support.

Identifying the patients needs (physical, psychological, behavioural)

Identifying and managing symptoms Support to carers and families.

Best Practices covering: Pain Assessment (reference to Pain

Pathway) Airway toileting and respiratory symptoms Physical hygiene Nausea Mouth care Tissue viability Bowel care Pastoral & Spiritual support.

What on For 2010

Re-launch –Let’s Respect campaign in collaboration with ‘Worried About you Memory’

What’s Your Story- Life Story Books Education -Modular programme (In

collaboration with Learning Development) Completion of RCHT Dementia Strategy and

Business Plan

Our Vision Countywide Education Program (NVQ

Training and diploma status – County Wide resource)

Countywide Network Forum Link Nurses for Dementia –RCHT End of Life –advanced planning

In Summary

There is excellent leadership and ownership in advocating for dementia care in RCHT allowing multidisciplinary assessments and shared care with the psychiatric liaison services.

Continuous drive to improve quality of care

The Royal Cornwall Hospital

People with passion and vision.