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  Bed base 538
 nTD = 69 (11%)  nTD=74(13%)
 nDementia=57(10%)  nDementia=57(10%)
 nDelerium=9(1%)  nDelerium=17(3%)
Correlation between delay in
discharge and those patients with
cognitive impairment
 A direct positive Correlation Between Delay in Discharge and the
Presence of Disability.
correlation between 1.25
delay in discharge and 1
0.75
those patients with 0.5

cognitive impairment D 0.25

e la y e d D is c h a rg e
who demonstrated 0
0 0.25 0.5 0.75 1 1.25

evidence of disability. Disability

y = 0.8333x
2
R = 0.7143

2008
 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 Pathways
Guidelines Pathways and other
 Behavioural Chart and
 Dementia
assessment tools
 Acute Confusion
 Cognitive assessment tools

 Palliative Care  PAINAD

 Pain management  Carers support

 Life story books

 Mental Capacity
 Communication Alert
 Anti-psychotic prescribing
scheme
 DOLS
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)
Other Related Activities
 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

 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
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 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.

6%
8%
30%
8%
Infection
Cardiac
Falls (no
9% fracture)
Stroke
Fractures
Not
Eating
Other

12%
27%
‘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
 Cognitive deficit identified: Chronic / Acute on Chronic / Acute

Diagnosis Dementia Suspected Dementia

Known
History
Check who made
diagnosis and date
Examination
No Does history include:
No Psychiatric Deteriorating cognition
input needed Investigations
Challenging behaviour
discharge as per Complex discharge
medical needs Cognitive Assessment
Yes

Is deterioration rapid Yes Identify and Treat

and unexplained? reversible factors
No
Contact Eldercare team
Nurse in a Calm Quiet Environment for definite diagnosis

For details of above flow

No Any psychiatric concerns? chart see following page
Risk to others / self?

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
 > 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
PAINAD
Items* 0 1 2 S
c
o
r
e
Breathing Normal Occasional laboured breathing. Noisy laboured breathing. Long
independent Short period of hyperventilation. period of hyperventilation.
of vocalization Cheyne-Stokes respirations.

Negative None Occasional moan or groan. Low- Repeated troubled calling out.
vocalization level speech with a negative or Loud moaning or groaning.
disapproving quality. Crying.

Facial Smiling Sad. Frightened. Frown. Facial grimacing.

expression or
inexpress
ive
Body language Relaxed Tense. Distressed pacing. Rigid. Fists clenched. Knees
Fidgeting. pulled up. Pulling or pushing
away. Striking out.

Consolability No need to Distracted or reassured by voice Unable to console, distract or

console
or touch. 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.