Transforming Dementia Care within Royal Cornwall Hospital Trusts

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Transforming Dementia Care within Royal Cornwall
Hospital Trusts

• Dr Fiona Boyd, Dementia Lead.
• Bev Chapman, PCT Lead
• Maggie Trevethan, Clinical Nurse Lead

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Past ,Present and Future

• Service development to date
• Ongoing projects
• Our vision

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To date.

• Ongoing over 5 years
• Shared care philosophy
• Designated clinical lead
• Designated ward base
• Collaborative working

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Long Term Condition

• Diagnosis
• Maintenance
• Complex
• Palliative

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Dementia Mapping - Comparison figures 2006-2008

• Bed base 588
• nTD 69 (11)
• nDementia57(10)
• nDelerium9(1)

• Bed base 538
• nTD74(13)
• nDementia57(10)
• nDelerium17(3)

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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

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• 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.

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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

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Guidelines and Pathways

• Guidelines
• 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

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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

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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)

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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)

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Other Related Activities

• OPMHG -Cornwall
• Participation in Developing Cornwall Strategy
• Regional Audit

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Joint PCT/RCHT Audit of Nursing Home Admissions

• Dr Fiona Boyd
• Bev Chapman
• Kylie Cook
• Maggie Trevethan

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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

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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 2 3 4   Reason for
admission   Diagnosis (es) 1 2 3 4     P
rescribing issues Yes /No If yes,
comment     Nursing needs Yes/No   If yes
date of request date actioned Review
date   Delaying factors     Place of
discharge     Possible alternatives to
admission  
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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

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Breakdown of Admission Types
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Other

• General breathlessness
• fatigue/exhaustion/SOB (12)
• Admission from CPT
• Step up care (4)

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Other important Findings

• Palliative 29 (32)
• Treatment feasible in the Home 64 (70)

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Whats 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

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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

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24 hour behavioural chart

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Guidelines Pain

• gt 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.

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Patients with Dementia

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

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PAINAD
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Guidelines Palliative

• Understand the drivers to improving end of life
  care for those with dementia
• Identifying terminal phase care
• Practical measures (care pathways)

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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.

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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.

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What on For 2010

• Re-launch Lets Respect campaign in
  collaboration with Worried About you Memory
• Whats Your Story- Life Story Books
• Education -Modular programme (In collaboration
  with Learning Development)
• Completion of RCHT Dementia Strategy and Business
  Plan

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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

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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

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The Royal Cornwall Hospital

• People with passion and vision.