Improving dementia care in the acute hospital

Transcription

1 Improving dementia care in the acute hospital Natalie Cole, PhD DemPath is an initiative funded by the Genio Trust

2 Impact on acute hospitals Increasing age profile: two thirds of inpatients are over 65 years 60% have or will develop a brain health problem in hospital Two thirds of brain health problems in hospital are due to either dementia or delirium (with underlying dementia) The acute hospital is becoming the last stop on the care-train for the person with dementia Who Cares Wins 2005

3 Multiple Journeys DemPath is an initiative funded by the Genio Trust

4 Irish National Audit of Dementia Care in Acute Hospitals 2014 Little dementia training and awareness programs Poor design features for people with dementia No dementia pathways in place DemPath is an initiative funded by the Genio Trust

5 St. James Hospital One of Ireland s largest teaching hospital 1000 bed acute hospital Approx. 3,500 staff DemPath large number of stakeholders

6 Education Design Integrated Care Pathway DemPath is an initiative funded by the Genio Trust

7 Training and Standardisation of assessments DemPath is an initiative funded by the Genio Trust

8 St. James s Hospital Dementia Training DemPath is an initiative funded by the Genio Trust

9 DemPath Facilitators

10 Environmental Design

11 ICP-what we found No standardised screening in ED for cognition/dementia/delirium Only ad hoc assessment for dementia through out the hospital No routine use of cognitive assessments No standardised screening or prevention for delirium Discharge letter provides little or no information on dementia Duplication of information collected by multiple people Multiple referrals for 2 nd opinion DemPath is an initiative funded by the Genio Trust

12 Developing an Integrated Care Pathway Advisory Group Consultation Key informant interviews Implement full pathway Surveys, focus groups Draft pathway Pilot pathway Process mapping Review of Best practice People with Dementia and Carers

13 Flagging of individual with Cognitive Impairment and /or Delirium

14 4AT The 4 A s Test (4AT) developed in 2011 as an assessment tool for identification of delirium and cognitive impairment in acute general hospital settings Among elderly patients, risk factors for delirium is dementia 2/3 of all cases of delirium occurring in patients with dementia/ cognitive impairment A recent validation study (2014) shows 89.7% sensitivity and 84.1% specificity of the 4AT for delirium. 4 Questions Alertness, AMT4, Attention, Acute Change or Fluctuating Course Less than 2 mins Best practice internationally e.g. NHS

15 Results of 4AT assessment of people over 65 presenting to SJH ED

16 Key developments Assessments for delirium and cognitive impairment implemented ED, Elective surgery Admission Recognizing delirium and cognitive impairment earlier Better communication of assessments untaken Amended discharge letter to capture results from ED and in-patient delirium and cognitive assessments

17 Key learnings to date No existing end-to-end ICP pathway to inform the DemPath ICP Gaps in whole hospital system Complexity of the process Need for buy-in from Corporate level for embedding of ICP Difficulties in embedding change of work flow in busy working environment

18 Next steps Embedding of assessments in workflow Improvements in interface with community healthcare providers Auditing and compliance Hospital Policy Sustainability of education and training Embedding of environmental design THANK YOU!

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20 Flow Diagram of SJH Cognitive Impairment and Delirium Pathway 4AT assessment in ED Delirium +/- Cognitive Impairment Delirium Prevention Pathway Possible Cognitive Impairment Decision to Admit Result of 4AT on EPR Decision to admit-result of 4AT on EPR Decision not to admit Identification and Treatment of Delirium by Medical Team SMMSE carried out by Medical Team Refer to OT in ED Delirium not resolved Medical Team repeats 4AT daily Referral to Specialist Team Pysch EL, MedEL Delirium Resolved Delirium +/_ Cognitive Impairment noted on discharge to GP and PHN Information to patients and/or carers on delirium +/- cognitive impairment Refer to Community Groups GP& PHN informed