Importance of standardised care for dementia in acute hospitals

January 29, 2014

The first Irish national audit of the quality of dementia care in Ireland's acute hospitals shows that Ireland does not yet have standardised care for dementia in acute hospitals. The audit showed differences in the access to dementia-relevant services between hospitals, with poor access to many diagnostic and support services.

Co-principal investigators on the audit were Professor in Geriatric Medicine Des O'Neill and Dr Sean Kennelly, Clinical Senior Lecture in Medial Gerontology from Trinity College Dublin along with Dr Suzanne Timmons and Paul Gallagher from University College Cork. Professor O'Neill and Dr Kennelly are members of both EngAGE, Trinity's Centre for Research in Ageing, and the Trinity College Institute of Neuroscience.

The audit also showed differences in the access to dementia-relevant services between hospitals, with poor access to many diagnostic and support services. There was inadequate assessment of cognition, delirium, mood, and behavioural and psychological symptoms, in people with dementia during their admission, and where assessed and discovered, issues were not highlighted on discharge. People with dementia admitted from nursing homes were least likely to have cognitive and social assessments and had the shortest length of stay in hospital. 35% of people with dementia admitted from home were discharged to nursing homes, and these patients had particularly long lengths of stay in hospital.

Up to 25% of patients in a typical general hospital may have a dementia at any one time (Cahill, O'Shea & Pierce, 2012), and dementia costs the state up to €21 million per annum. Improving the quality of care received by people with dementia in hospital could decrease the overall cost of , reduce staff and carer burden, and importantly, lead to more positive health outcomes for people with dementia.

In 2013, the Irish National Audit of Dementia audited 35 acute hospitals in the Republic of Ireland, interviewing the senior hospital managers and geriatricians; directly observing the environment/ interviewing the clinical nurse manager of 77 wards, and reviewing 660 healthcare records of people with dementia who had been admitted to the hospitals.

The Irish National Audit of Dementia is a joint initiative carried out by the Centre for Gerontology and Rehabilitation, University College Cork, The Centre for Ageing, Neuroscience and the Humanities, Trinity Centre for Health Sciences, Tallaght Hospital Dublin and the HSE Quality and Patient Safety Directorate.

Key Findings of the Audit:

Demographics and Assessment

  • 35% of people with dementia admitted from home were discharged to nursing homes
  • The average length of stay for a person with dementia admitted from home and discharged to a nursing home was 59 days, compared to 22 days in a person admitted from home and discharged home.
  • The actual practice as evidenced by the healthcare records (HCR) was less than the stated practice by senior managers and clinicians in each hospital: 62% of hospitals reported that an assessment of functioning using a standardised instrument is routinely carried out, but 36% of patients had this performed; 97% of hospitals reported that nutritional assessments were routinely performed, but 76% of patients had a nutritional assessment recorded; 88% of hospitals reported that the person's weight or body mass index (BMI) would be routinely recorded during the admission, but 39% of patients with dementia had their weight or BMI recorded.
  • Only 43% of the people with dementia had a standardised cognitive test recorded in their HCR (dropping to 20% of those admitted from residential care); 30% were assessed for indicators of delirium; 14% were assessed for recent changes in mood; 20% received a social and environmental assessment.

Services Available and Ward Practices

  • While the majority of wards (96%) reported they had some level of access to liaison psychiatry, 26% had no access to psychiatry of old age services. The results also highlighted a significant lack of psychology services (91% of wards had no access), specialist continence services (66% of wards had no access), and social work services (47% of wards had no access).
  • 11% of hospitals (16% or wards) reported having no access to geriatric medicine services and 21% of wards had no access to occupational therapy.
  • 92% of wards reported that staff are encouraged to report patients missing/uneaten meals to ward managers; 92% of wards were able to provide food to patients between mealtimes; 75% of wards could provide adapted utensils to facilitate patients eating independently.
  • 79% of wards provided information about ward routines such as mealtimes and visiting hours verbally, 26% of wards provided this information in written format with 13% of wards providing information in both formats.
  • 5% of wards provide information on the complaints procedure verbally, 10% provide this information in written format.

Staffing, Training, Challenging Behaviour and Antipsychotic Medication

  • Over a third of wards (35%) audited have unfilled nursing vacancies, and 26% of wards have unfilled healthcare assistant vacancies.
  • 92% of wards have agreed minimum staffing levels across all shifts but only 69% of wards meet their agreed minimum staffing levels.
  • 65% of wards had a system in place to ensure adequate staffing levels at mealtimes to support eating and choose food if necessary.
  • No hospitals have mandatory dementia awareness education/training for any staff.
  • 38% of wards had arrangements in place that would allow staff to attend training relating to the care of people with dementia.
  • 50% of hospitals have, or are developing, a protocol governing the use of interventions for patients displaying violent or challenging behaviour, aggression and extreme agitation, which is suitable for use in people with dementia who present with behavioural and psychological issues (BPSD). However, only 18% of these hospitals reported that their protocol has specific evidence-based guidelines for the prescription and administration of antipsychotic drugs.
  • Just under a quarter of patients were prescribed a new antipsychotic to be given regularly or as needed their admission. A reason for the prescription was recorded in only 50% of cases, most commonly for 'agitation'.

Suitability of the Ward Environment for People with Dementia

  • No hospitals used colour schemes to help people with dementia find their way around.
  • The flooring in the majority of hospitals was appropriate for a person with dementia, with 92% of floors plain/subtly patterned, 82% subtly polished and 88% of floors with non-slip surfaces.
  • Just under half of wards (42%) had key areas (e.g. nurses station) clearly marked.
  • The majority of hospitals (65%) had signs/maps to help direct and orientate patients, but only 12% were large, bold and distinctive, making them appropriate for a person with .
  • 21% of wards had a clock visible from each bed.
  • Signs to locate the toilet were not visible from the patient's bed area/door of their room on the majority of wards (74%).
  • 35% of wards had signs on all their toilet doors. Even fewer wards (29%) had signs on all their bathroom doors.
  • Hand rails were present in the majority of wards (91%), while large handles (on taps and doors) were present in 75% of wards. A raised toilet seat was present in only 42% of wards.

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