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
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Service development to date
Ongoing projects
Our vision
To date.
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Ongoing over 5 years
Shared care philosophy
Designated clinical lead
Designated ward base
Collaborative working
Long Term Condition
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Diagnosis
Maintenance
Complex
Palliative
Dementia Mapping Comparison figures 2006-2008
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Bed base 588
nTD = 69 (11%)
nDementia=57(10%)
nDelerium=9(1%)
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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.
Delayed Discharge
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1.25
1
0.75
0.5
0.25
0
0
0.25
0.5
0.75
Disability
1
1.25
y = 0.8333x
2
R = 0.7143
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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.
The RCHT Memory Service
provides
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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 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
Education and Awareness
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Local to RCHT:
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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
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Regional:
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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
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National:
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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)
Other Related Activities
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OPMHG -Cornwall
Participation in Developing Cornwall
Strategy
Regional Audit
Joint PCT/RCHT Audit of
Nursing Home Admissions
Dr Fiona Boyd
Bev Chapman
Kylie Cook
Maggie Trevethan
Aims
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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
DOA
DOD
Time of admission
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
Prescribing issues: Yes /No
If yes, comment:
Nursing needs: Yes/No
If yes:
date of request
Delaying factors
Place of discharge
Possible alternatives to admission
date actioned
Review date
Provisional Data Jan-March
2009
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Total Number Admissions 91
Length of Stay 1421 bed days
See by GP before admission 27 (30%)
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Required admission 10 (37% of reviews; n/11% )
Seen ‘Out of Hours’ 59%
Breakdown of Admission Types
Reasons for Admission to RCHT.
8%
6%
30%
8%
Infection
Cardiac
Falls (no
fracture)
Stroke
Fractures
Not
Eating
Other
9%
12%
27%
‘Other’
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General breathlessness
– fatigue/exhaustion/SOB (12%)
Admission from CPT
Step up care (4%)
Other important Findings
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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
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Guidelines: Dementia
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Section 1
Section 2
Section 3
Section 4
Section 5
Section 6
Section 7
Section 8
Dementia Pathway Summary
What To Do on Admission and Why.
How to Manage Difficult Behaviours.
Dementia Assessment Tools and Care Plans
Discharge Planning and Who To Contact.
Assessing Capacity.
Contact List of Community Mental Health Teams
Appendices of Assessment Tools and Care Plans
Cognitive deficit identified: Chronic / Acute on Chronic / Acute
Diagnosis
Known
Dementia
Suspected Dementia
History
Check who made
diagnosis and date
Examination
No
No Psychiatric
input needed
discharge as per
medical needs
Does history include:
Deteriorating cognition
Challenging behaviour
Complex discharge
Investigations
Cognitive Assessment
Yes
Is deterioration rapid
and unexplained?
Yes
No
Nurse in a Calm Quiet Environment
No
Any psychiatric concerns?
Risk to others / self?
Identify and Treat
reversible factors
Contact Eldercare team
for definite diagnosis
For details of above flow
chart see following page
Yes
Contact eldercare psychiatric liaison team via switchboard
If unavailable contact on call mental health services on ext 1300
Consider using section 5(2) Mental Health Act if necessary
Using 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.
24 hour behavioural chart
Time 24hrs
Agitation/
Restlessness
Violence/
Aggression
Care Refusal
Wandering
Fall
Pain
Sleep Disturbance
Settled
Guidelines : Pain
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> 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
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Experience communication difficulties
Lack understanding
Interpret and express their pain in ways
PAINAD
S
c
o
r
e
Items*
0
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. Lowlevel speech with a negative or
disapproving quality.
Repeated troubled calling out.
Loud moaning or groaning.
Crying.
Facial
expression
Smiling
or
inexpress
ive
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.
1
2
Total**
Guidelines: Palliative
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Understand the drivers to improving end of
life care for those with dementia
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Identifying terminal phase care
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Practical measures (care pathways)
Key Aims:
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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:
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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
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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
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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.