Transcript Slide 1
National Audit of Dementia
(care in general hospitals)
Partners to the audit
Background
• CCQI scoping report for Healthcare Commission 2007:
• Finding that care of people with dementia in general
hospitals is high priority for audit
- In a typical 500 bed general hospital, 20% admissions
will have dementia (Who Cares Wins, 2005)
- Hospitals can be ill prepared and care can be
inconsistent
- People with dementia experience worsening of condition
and poor outcomes
Participation in the audit
Participation in the core audit
• 210 or 89% hospitals
• 99% Trust participation
• 210 checklists
• 7934 case notes of people with dementia
Participation in the enhanced audit
• 55 hospitals (145 wards)
• 144 environmental checklists
• 145 ward checklists
• 2211 staff questionnaires
• 245 patient questionnaires
• 608 observations of care interactions
Key findings
•6% of hospitals had a care pathway
•44% of hospitals had a care pathway in development.
8
8
6
Delayed
discharge and
re-admission
Delayed
discharge and
re-admission
and falls
20
Re-admission
31
Delayed
discharge
100
90
80
70
60
50
40
30
20
10
0
Falls
% of hospitals
•Information reviewed by the Executive Board:
Notice of discharge provided
100.0
National
90.0
80.0
% of casenotes
70.0
60.0
National
50.0
40.0
30.0
20.0
10.0
.0
Less than 24
hours
24 hours
24-48 hours
More than 48 No notice at all
hours
N/A
Not
documented
Summary
•Lack of leadership both at Trust/Health Board level and at
hospital level.
In terms of identifying champions and leads, and identifying
required resources.
•Trust Boards/Health Boards require better intelligence and
information on admission, care, treatment and discharge of
people with dementia.
Improvements can be made to processes and overall
governance.
Key findings
•
13% of casenotes
assessment.
no
formal
pressure
sore
risk
•
19% of casenotes not asked about any continence
needs as part of assessment.
•
24% of casenotes not asked about any pain as part of
the assessment.
Summary
•
Gap between policy and practice. Adherence
multidisciplinary assessment procedures should
clarified and reinforced.
to
be
Key findings
•
28% of people with dementia received antipsychotic
medication in the hospital.
Existing prescription
of antipsychotics
only
16%
7%
5%
72%
New
prescription/PRN or
both administered
during admission
Existing prescription
on admission and
new prescription/PRN
or both administered
during admission
No antipsychotics
Summary
•Widespread provision of liaison psychiatry but lack at evenings and
weekends.
Likely to impact on the time taken by services to respond to an
emergency or urgent referral.
A lack of mental health assessment during admission and discharge
- mental health needs often overlooked
May affect ability to carry out assessment or to see patients who
require onward referral for diagnosis.
Hospitals should ensure challenging behaviour is managed with
awareness and understanding, guidelines are reviewed and training
for staff is in place.
If antipsychotic medication prescribed, a reason should be recorded
and it should be reviewed regularly.
Summary
•Much could be done at hospital level and ward level to
improve nutritional standards:
Standardised assessment and recording of weight over time.
Support to assist patients at mealtimes.
Making food available at other times.
Implementation of protected mealtimes.
Summary
• Lack of guidance in hospitals for involving families in
discharge and support arrangements
Families not routinely involved in care and often
not given named healthcare professional to contact
for help.
• Ward systems for recording and communicating basic
personal information about patients with dementia
This information
assessment.
not
a
systematic
part
of
Summary
• Patients’ families/carers not asked about behaviours that
may indicate distress or useful strategies to help the patient
feel safe and calm.
This information could reduce the behaviour disturbance and
avoid antipsychotic medication.
• Hospitals need clear guidelines on information to be
collected, and on supporting staff to share and use
information and involve carers
Percentage of staff answering 'sufficient'
Training areas
100
90
80
70
60
50
40
30
20
10
0
67
50
46
32
33
66
52
42
Summary
• 96% of staff agreed further training on dementia awareness
needed to improve the care people with dementia receive.
• Comments on particular aspects of care reveal that
further training is needed across all job roles for a range of
competencies related to the care of people with dementia.
Summary
• The experience of people with dementia could be
improved by
attention to orientation both in the ward (signage, use of
colour) and the bed area (positioning of familiar personal
items)
use of space to provide breaks from the ward environment
• Evidence from observations of care also suggested
that attention to noise and creating a warm, friendly
atmosphere are important in the care of people with
dementia
Key findings - casenotes
• 67% up-to-date discharge plan.
• 58% evidence that support needs identified in the
discharge plan.
• Only 41% showed a copy of the plan passed on to
patients or carers.
• 75% assessment of the carer’s current needs had taken
place before discharge.
• 80% place of discharge and support needs discussed with
carer/relative.
Information collected to support care
90
National
80
% of casenotes
70
60
50
National
40
30
20
10
0
Personal details
Support with
personal care
Factors that distress
Support to calm
Life details
Summary
• It is encouraging that:
Most casenotes show evidence of attention to the carers’
needs
most showed involvement of the carer in discharge and
support.
• But:
in half the casenotes discharge planning had not begun at
admission, for no stated reason.
half had no named discharge co-ordinator
• Early discharge planning helps timely discharge and
reduces time spent by the person with dementia in the
acute environment - cost savings
Training and communication
• 5% hospitals said that dementia training
• (care provision, systems, information and resources available
in the hospital) mandatory for all healthcare staff
• 16% hospitals said training was available not mandatory for
all staff or some key staff
• Over 90% of all staff agreed further training would improve
the level of care received by people with dementia
Key findings
•
On most hospital wards there is little evidence of a personcentred ward approach or ‘culture’, or that the care received by
patients is generally person-centred.
•
The content of the staff/patient encounter is mainly task related
and delivered in an impersonal manner.
•
Periods of care-based activity interspersed with inactivity
leading to lack of attention, lack of stimulation and boredom for
patients.
•
Environment is often impersonal and not dementia friendly
excess noise at times, lack of orienting cues, no areas for
socialising.
Information on the ward – staff
comments
Staff comments:
“These systems are in place, but due to high numbers of agency staff
that are unfamiliar with documentation these systems are not always
effective”
“Although staff do communicate with one another I feel there is lacking
handover information especially to nursing assistants”
“A minimal handover is given with the most basic of information, due
to cutting time. Extra information is ideal but not realistic on this ward”
“We now have a booklet on the ward for patients and/or family to fill in
to help.”
“There is NO WAY EVER enough time to collect or even read the
personal information for the patient”
Information and communication observations
•
•
•
•
About half of the wards identified this as an area in need of
improvement
One patient had preferences to his drinks (like and dislikes), staff ensured he
had his favourites at hand (this was important as his oral intake needed
encouragement).’
Feedback noted where improved communication could have
anticipated and prevented problems:
Not all staff were aware of personal preferences in terms of patient
care/choices e.g. likes and dislikes in diet and drinks. One patient reported
they liked their water warm, staff brought a glass of cold water, the patient said
they liked warm water and the water was cold and couldn’t take their medicine.
Improving quality of care
• Local reporting shows comparison with national level data
on each of the criteria
• Hospitals were asked to produce action plans
• Wards participating in observation highlighted areas for
celebration and improvement
• National report made recommendations for improvement
and focused on identified good practice
• A second round of audit begins in Spring 2012 - this
repeats hospital audit
• A new project, the Quality Mark for Elder-Friendly care, is in
development, and will build on the results of the ward level
audit
A call to action from you!
• Urgent need for research to find a cure for Alzheimer’s and
other forms of dementia
• Developing prevention of a cure and getting it into
widespread use could take 10, 20 or even 30 years
• There is also an urgent need to improve dementia care now
• Audits and service improvements are useful but limited
• Need to support research to improve dementia care develop interventions, what works, what’s cost effective?
• In last few years Dept of Health funding for dementia care
research has increased significantly
• Alzheimers Research UK and Alzheimers Society 113
projects and only 8 (7%) on improving care
• Action needed from DAA to value, encourage and support
dementia care research