By Dr Daryl Leung, Clinical Director
Care of the Elderly
New Cross Hospital.
Dr Elizabeth Ward, Specialist Registrar
Care of the Elderly
New Cross Hospital.
This project aims, with a holistic and comprehensive design, to improve acute dementia care in the district general hospital.
Acute physical illness and the care for dementia patients with delirium, falls, infections and frailty pose district general hospitals with multiple problems(1, 2, 4). Social issues and lack of resources in the community delay discharge. Neuroleptic medication too often replaces expert dementia care(3, 7). Increased morbidity, admission to twenty four hour care, loss of independence and death result; all are previously well documented.
The project was proposed by NHS West Midlands via Pauline Smith and Karim Saad.
The Chief Executive David Loughton CBE and the Director of Nursing Cheryl Etches accepted the project for New Cross Hospital, almost eighteen months ago.
Grace Hampson is the Project Manager and Daryl Leung is the Clinical Lead Geriatrician.
Lead roles taken by Professor Dawn Brooker, Head of Department of Dementia at Worcester University, and Dr Roger Resar from America, have given specific advice for Care Bundle design and implementation(5).
Aims and Design
The Project’s aims are to improve dementia care in the acute setting. Hard end points include reduced length of stay, better quality care – as evidenced by reduced discharges to 24 hour care and improved carer and patient satisfaction survey results(1, 3) - coupled with comprehensive education for all acute staff caring for dementia patients (hostesses, porters, nurses, and doctors alike).
A whole systems approach is required as described below:
The new ward has 20 beds for dementia and physical illness. Special features include a dining area, a relative’s bedroom, a reminiscence area from which activities will run daily and a garden. The Kings Fund provided funding for the above as well as new cubicles in our medical assessment unit(6).
Staff and Education
We have established admission criteria for the ward and will have an Outreach Dementia Service as well as an appointed Consultant Nurse.
We also have an Educational Nurse for dementia (Gillian Maidens) and are running training programmes for all hospital staff including training our Elderly Care Nurses specifically in dementia care, our Care Bundle and an “About Me” document. Other key components are our trained volunteers, Physiotherapists, Occupational Therapists and Psychogeriatric Liaison Team.
This involves work before, during and after admission. We have been in close liaison with Primary Care, General Practitioners and Social Services to achieve this. We have looked particularly at facilitating discharge, including rehabilitation facilities for dementia patients (at present there are none in Wolverhampton).
Audit and Evaluation
A point prevalence study of dementia throughout the hospital has been done and we, like most hospitals, have been involved in the National Audit in Dementia. We are currently auditing the use of neuroleptic medication across the Trust.
There is external evaluation of the project from an economic and patient perspective by Professor Dominic Upton, Worcester University.
This whole system is backed by a new database and new IT facilities.
There are two parts of the pathway we would particularly like to highlight; namely the Care Bundle and the “About Me” document.
The Care Bundle
Our Care Bundle was devised with the help of Professor Dawn Brooker from Worcester Department of Dementia Studies and Dr Roger Resar from the States(5). It requires regular and repeated focus of three main facets; (1) enhanced communication through the “About Me” and “Reach Out” documents, (2) hydration and nutrition and (3) concentration on the appropriate environment.
The Purpose of the “About Me” Document
The “About Me” document is designed to gain a deeper understanding of the patient. It helps tailor a nurse care plan to the individual needs of the dementia patient in the acute hospital setting. If we don’t understand our patients how can we address their needs and fears.
The whole project is a work in progress. The learning curve for all involved has been a steep but exciting process.
Thanks are owed to so many people including Pauline Smith & Karim Saad from NHS West Midlands, Grace Hampson our Project Lead and everyone at New Cross Hospital (especially David Loughton CBE CEO and Cheryl Etches Director of Nursing).
Thanks are also due to Matron Karen Bowley, Sister Rose Mathewson, John Homer our Carer’s Representative and Lynn Fieldhouse Lead for Trust Education.
An updated and more definitive version of this article appears on the British Geriatrics Society website (published December 15th 2010). The new version includes more information on the patient pathway, with diagrams.
A further BGS update, entitled “The New Cross Dementia Care Bundle - Thinking Straight, Acting Collectively” appeared on April 14th 2011.
1. Alzheimer’s Society (2009). Counting the cost: caring for people with dementia on hospital wards. London: Alzheimer’s Society.
2. DoH (2009). National dementia strategy: living well with dementia. Leeds: Department of Health, 2009.
3. DoH (2010). Quality outcomes for people with dementia: building on the work of the National Dementia Strategy. Leeds: Department of Health, 2010.
4. Leung, D. Todd, J. Dementia Care in the Acute District General Hospital. Clinical Medicine, Journal of the Royal College of Physicians. Vol.10(3), June 2010, pp.220-222.
5. Resar, R. Pronovost, P. Haraden, C.[et al] (2005). Using a bundle approach to improve ventilator care processes and reduce ventilator-associated pneumonia. Journal of Quality Patient Safety, 2005, Vol.31(5), pp.243-8.
6. The King’s Fund (2009) Enhancing the healing environment: a guide to NHS Trusts. London: The King’s Fund, 2009.
7. Thomas, P. Leung, D. Re: Anti-psychotics and risk of venous thromboembolism: implications for patients with dementia. e-BMJ September 28th 2010.