Setting up the “Beacon wards” Colin MacDonald Alzheimer Scotland Nurse Consultant NHS Lothian

The disabling impact of Dementia..? Being in hospital: “Had a significant negative effect on general physical health” “Had a significant negative effect on symptoms of dementia – with increased confusion and dependency” “Increased length of stay” “More likely to be prescribed anti-psychotic drugs” “Increased prevalence (34%) of being admitted to a Care Home” (Counting the Cost - Alzheimer’s Society 2009) But staff most staff do not come to their work to do a bad job!

Dementia “Beacon ward” project (One year audit cycle from Nov 2009 – Nov 2010) So what did we do….? Baseline audit – patient info system (TRAK) - case note audit Set up 5 “beacon” areas Environmental and practice review Education and support Signed up to 10 “good practice statements”

Examples of actions and support (by Alzheimer Scotland Nurse Consultant)  Education + support: Routine visits Educational materials and resources Dementia awareness sessions Hands on coaching / support (working with staff)

Examples of actions and support Good practice statement 4: Screening and assessment “Any signs of confusion in older people will be screened for Dementia, Delirium or Depression (evidenced in notes)” Good practice statement 7: Behaviour that challenges “A systematic approach towards understanding the cause or origins of behaviour is adopted. This will include pain, environmental stimuli, and staff approaches”. Introduced: Doloplus 2 - pain 4AT – Delirium Cornell – Depression Challenging behaviour process and checklist

Good practice statement 5: Dementia friendly environment: “A sign on every toilet door” “A clock in every patient area” Examples of actions and support

Audit results - Phase 1 (TRAK info) Nov 2009 Nov 2010 Total number of patients with dementia Average age 8483 Average length of stay (days) 3017 Average ward moves per patient Reduced length of stay and moves per patient. Nov 2009 Nov 2010 Home36%42% Care home10%20% Other NHS or LTC42%27% % discharged to (any) LTC 52%47% More patients going directly home from hospital. Less patients going to LTC from hospital.

Audit results - Phase 2 (case notes) Nov 2009Nov 2010 Psychotropic meds prescribed in hospital24%7% Catheter30%3% Only two patients (7%) Rx psychotropic meds during stay – in sharp contrast to criticisms reported elsewhere (Alzheimer’s society 2009, MWC 2011) Only one patient had a catheter inserted (3%) during their stay. (Catheters are regarded as a high risk factor in people with dementia due to potential cause of infection, trauma and delirium).

Audit results - carer survey  Carers who rated their involvement in care / treatment as good or very good increased from 36% to 64%  Carers views on staff awareness and knowledge of dementia rated as good or very good increased from 41% to 70%  Carers views on their involvement in discharge planning rated as good or very good increased from 30% to 47% “All the nurses did a good job. It was great to get him back to his old self again and to get him back home” (Carer).

Audit results - staff survey  The number of staff who have attended dementia training in the past 5 years increased from 12% to 45% “There is much more of a focus on dementia now. I have learned a lot in the last year. I wondered what I did or how I managed before” (Staff nurse).  The number of staff who described their awareness and ability of meeting the needs of people with dementia as good or very good increased from 38% to 86%. “I always thought that medications were the best approach – but now know that it is not the best. We can have a big influence on our patients care without meds” (staff nurse).

Audit results - staff survey  Reduction in all areas of impact on staff – especially stress, frustration and fear: - reduced feelings of frustration from 82% to 48% - reduced feelings of stress from 46% to 34% - reduced feelings of fear from 30% to 14% “I just try to understand them more now. I can always step back and try again later...or someone else can try” (staff nurse).

Final point At a time when the General hospital is coming under increased scrutiny and criticism in its care and treatment of people with dementia this audit project has indicated the positive trends that can be achieved. The efforts and commitment of all staff involved in this project should be acknowledged and congratulated.

Thank you