National Audit of Dementia

Transcription

1 National Audit of Dementia (Care in General Hospitals) Date: December 2010 Preliminary of the Core Audit Commissioned by: Healthcare Quality Improvement Partnership (HQIP) Conducted by: Royal College of Psychiatrists Centre for Quality Improvement Advised and approved by: National Audit of Dementia Steering Group 1

2 National Audit of Dementia (Care in General Hospitals) Preliminary of the Core Audit In this interim report we summarise the key findings from a preliminary analysis of aggregated hospital-level data collected as part of the core audit of the National Audit of Dementia. All but one of the 151 provider organisations in England and Wales that were eligible to participate took part in the audit and 210 hospitals (88% of the total number) submitted data. The final report for the first wave of the national audit, which will be published in late 2011, will include findings from a more in-depth evaluation of practice at the level of the hospital ward and recommendations informed by action planning events that will take place in the spring and early summer of This short interim report is published at this time so that there will be no delay in making preliminary findings public. The aggregated results reported here were based on data collected from: i. a hospital organisational checklist to audit the service structures, policies, care processes and key staff that impact on service planning and provision for people with dementia. This part of the audit was carried out between March and May 2010 and involved 210 hospitals. ii. a retrospective casenote audit of the records of 40 patients with a diagnosis or current history of dementia. This compared actual practice with standards that relate to admission, assessment, care planning/delivery, and discharge. The sample of casenotes was of 7934 patients discharged between 1st September 2009 and 28th February 2010, and data was submitted by 206 hospitals. Audit was of a single admission, and eligible admissions were of five days or longer. Inevitably, the report focuses on areas of performance that are relatively poor. When reading this report, it is important to remember that these are the aggregated results from a large number of hospitals and that the findings say nothing about the quality of care in any individual hospital. The audit tools and a full breakdown of national results can be viewed at Key for descriptors of quantity used in this document: >80% Most 20-44% A minority 56-80% The majority <20% A few 45-55% About one half <10% Very few 2

3 Key findings 1. How comprehensive is the assessment made by doctors and nurses of the mental and physical health needs of people with dementia who are admitted to hospital? If clinicians do not assess an older person s mental state when they are admitted to hospital, they might miss the fact that the person has dementia. Also, people who do have dementia are at greater risk of developing delirium (a serious condition causing acute confusion, which can arise from a medical problem such as infection, or after surgery, or sometimes as a side effect of some medications). If clinicians do not assess cognitive function at admission, they might miss the subsequent development of delirium. The majority of hospitals stated that it was their policy that assessment for people with dementia should include mental state assessment. However: Fewer than half of the casenotes in the sample showed that patients had received a standard mental status test, and very few had been assessed for delirium, or been formally tested for the presence of depression. Nutrition and hydration are essential to treatment and recovery. Four out of ten older people admitted to hospital may already be suffering from malnutrition, and one in five patients who have trouble feeding themselves do not get help (according to a 2009 survey of inpatients by the Care Quality Commission). Most hospitals stated that procedures were in place to ensure a nutritional assessment would be carried out and that patients were weighed on admission. However: Nutritional assessment had not been recorded in almost a third of the audited casenotes; Of casenotes with an assessment, a minority contained no recording of the patient s weight. 3

4 2. What information do hospitals collect to help them care for people with dementia? People with dementia may have difficulty in talking to hospital staff or communicating when they are distressed due to pain or other physical discomfort. A carer or relative can provide vital information which will help hospital staff to provide better care and to detect signs of deterioration in the person s physical or mental health. Carers and relatives can also inform staff about good/bad times of day, food requirements, what the person might need help with or reminding about (eating, drinking, personal care and hygiene) and things that are likely to cause anxiety, distress or anger. They can also give staff information about the names of loved ones, pets, current or former occupation all of which can assist staff to provide more person-centred care. A minority of hospitals said that they had a formal system in place for gathering information pertinent to caring for person with dementia. A minority of the casenotes contained a section dedicated to collecting information from the carer, next of kin or a person who knows the patient well. This varied at site level, with some hospitals not collecting information for any patients in the sample and some for 100% of casenotes. When information was collected, the type of information recorded varied. Information was most often collected about whether the person needed reminders or support with personal care. Less than half collected information on personal details and preferences. A minority contained information on recurring factors which could cause or exacerbate distress, or on support or actions which could calm the person if necessary. 3. Do hospital policies recognise the needs of people with dementia and aim to safeguard them against longer admissions? Because of the problems that people with dementia encounter when in hospital, it is important that they are identified separately as a vulnerable group of patients. Hospitals should routinely check and review how many people with dementia: have falls, make complaints, have delayed discharges or are readmitted soon after discharge. Unless this is done, hospitals cannot detect and address these issues that, as well as endangering patients, adversely affect efficiency and cost effectiveness of care. 4

5 Awareness and recognition of the diagnosis of dementia are also important at the ward level. If staff are not aware of the condition in someone admitted to hospital this can lead to under assessment of care need and heighten risk, e.g. of an inappropriate response by staff to behavioural and psychological symptoms of dementia, or of inadequate care support which can compromise personal dignity. Less than one-third of hospitals were able to identify people with dementia within reported information on in-hospital falls and their causes. A minority of hospital boards routinely reviewed delayed discharge and very few routinely reviewed readmissions of patients with dementia. A minority of hospital boards regularly reviewed feedback, with regards to patients with dementia, from clinical leaders, PALS or patient forums, or analyse complaints received by age. Few hospitals said that they had in place a system to ensure that staff on the ward were aware that a person had dementia and how it affected them, and that necessary information was imparted to other staff with whom the person came into contact. 4. Are staff in hospitals trained to be aware of and consider the needs of people with dementia, including memory and communication problems? Because so many people admitted to hospital have dementia, it is important that all ward staff have the basic skills required to work with this patient group. For example, staff working with people with dementia should be trained in effective approaches to extreme agitation or aggression in a person with dementia, including calming or distracting techniques. If this is not done it can lead to increased risk of the use of sedation and to inappropriate response to symptoms of other mental and physical health conditions or symptoms. Very few hospitals reported that training in awareness of dementia was mandatory for all staff. In the majority of hospitals, the training and knowledge framework/ strategy did not identify necessary skill development in working with and caring for people 5

6 with dementia and also did not specify that staff of all grades and disciplines should have access to communication skills training involving older service users. In addition, in only a minority of hospitals did the strategy specify that staff working with people with dementia were trained in anticipating behaviour that challenges and how to manage violence, aggression and extreme agitation, including de-escalation techniques. The majority of hospitals reported that staff received training in assessing capacity and an understanding of the Mental Capacity Act, and in awareness of how to support people with visual or hearing impairments. Most hospitals said staff working with people with dementia were trained in protection of vulnerable adults. A minority reported that they involved people with dementia and carers or feedback from their experiences in the training for ward staff. 5. Do hospitals have a policy or protocol in place governing interventions for patients displaying violent or challenging behaviours, aggression and extreme agitation, suitable for use with people with dementia? People with dementia can experience a range of cognitive and emotional symptoms associated with their condition and this can have an effect on behaviour, sometimes leading to extreme distress and agitation or aggression. Other sources of stress such as pain, illness or unfamiliar surroundings can often make this worse. Failure to recognise and manage these situations proactively can lead to inappropriate prescription of antipsychotic drugs for behavioural control. The majority of hospitals reported that they did not have a policy/ protocol in place for these circumstances. Most, but not all, hospitals that had a protocol reported that the protocol specified that restraint and sedation were only used as final options and where justified as in the best interests of the person with dementia. 6

7 6. How many people with dementia in the sample were prescribed antipsychotic drugs in hospital? Because of the risk of adverse reactions, people with dementia should only be prescribed antipsychotics if they are severely distressed, in significant distress over time or are at immediate risk of causing harm to themselves or others. The Department of Health is committed to reducing the use of antipsychotics prescribed to people with dementia by two-thirds by November A minority of people with dementia in the sample were prescribed an antipsychotic drug. However for less than a third of these patients was the drug newly prescribed during their admission to hospital (most patients had therefore had their prescription made in the community). The most common recorded reason for prescription was agitation/ anxiety. Most, but not all, patients who had a prescription for antipsychotics, had the reason for the prescription recorded in their casenotes. 7. Are liaison psychiatry services available in hospitals? Such teams, which comprise mental health specialists (mostly psychiatrists and mental health nurses) can help provide diagnosis of dementia and depression, review of care and medication and advice about appropriate discharge planning. Most participating hospitals stated that access to a liaison service was available which could provide assessment and treatment to adults throughout the hospital. The majority of hospitals with a service reported that there was a named consultant psychiatrist and half of these that the consultant psychiatrist had dedicated time allocated for liaison and was also a specialist in the care and treatment of older people. Less than a fifth of the casenotes audited recorded a referral to liaison psychiatry. Less than half of these were seen within 48 hours. Over one third had not been seen after 96 hours. 7

8 8. How do hospitals support the people who care for people with dementia? Caring for a relative or friend with dementia can be stressful and contribute to mental and physical ill health in the carer. Admission to residential or nursing care following admission can be precipitated by carer breakdown where the carer is unable to continue caring due to lack of support. For these reasons, ward teams must both support carers to maintain their relationship during admission and ensure that they remain involved in decisions about care. Ward staff should recommend that carers are assessed for their own needs and ability to continue as a carer. It is particularly important that they are given proper notice of discharge. A minority of hospitals had guidelines in place to ensure that the carer knows how much information will be shared with them, and the extent to which they can be involved in caring for the person with dementia during admission. Around half of the hospitals reported that their guidelines included asking the carer about their wishes and ability to provide care and support to the person with dementia after discharge. The majority of hospitals stated that there was a system in place to ensure that carers were informed about obtaining a carer s assessment and support. The majority of the casenotes contained evidence that an assessment of the carer s current needs had taken place in advance of discharge (unless the carer did not want or need one). Evidence about notice about discharge from hospital recorded in the casenotes showed that in a few cases no notice had been given, or notice was less than 24 hours. For almost a third, notice of discharge was more than 48 hours. 8

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10 Contact the National Audit of Dementia Team Chloe Hood Programme Manager Aarti Gandesha Project Worker Renata Souza Project Worker Stacey Dicks Project Worker Royal College of Psychiatrists Centre for Quality Improvement 4 th Floor Standon House 21 Mansell Street London E1 8AA The Royal College of Psychiatrists is a charity registered in England and Wales (228636) and in Scotland (SC038369) 2010 The Royal College of Psychiatrists 10