Jupiter Ward Dementia Friendly Environment report Introduction: Background. Evidence for change 1, 2, 3, 4, 6 :

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1 Jupiter Ward Dementia Friendly Environment report Introduction: Jupiter ward is a 3 bedded Older Persons Care (OPC) ward which re-opened in November 214 following a total refurbishment. The project involved re-designing Jupiter ward into a dementia Friendly environment 1, 2, 4. This report is an early look at the impact of those changes on the care experience of patients admitted to Jupiter ward. As it can take 12 months to track a true trend, this report can only be suggestive of a causal link between the care experience and the environment. Monitoring and data analysis will continue. Background In November 213 the Department of Health published A state of the nation report on dementia care and support in England which made the following comment with regard to dementia care in hospitals; An estimated 2% of hospital beds are occupied by people with dementia 1. People with dementia also stay in hospital for longer, are more likely to be re-admitted and more likely to die than patients admitted for the same reason who do not have dementia 1. In 21 the approximate number of people living in Swindon with dementia was 2,17. Based on current projections this figure is expected to increase by 41% to 2,977 by 221. In Wiltshire the number of people with dementia in 212 was 38 and is projected to rise to 8,338 by 22. People with dementia who are admitted to acute hospitals as a demographic group have poorer outcomes, with a greater risk of delirium, prolonged length of stay and death. Using the audit tools and design principles of the Kings Fund award winning Enhancing the healing environment programme GWH s first dementia friendly ward opened in November 214 after a 98, refurbishment project, funded by a grant from the Brighter Futures Charity. This specialist ward is designed to enable patients with dementia to be cared for in an environment which supports their complex needs and improves their hospital experience. The development of a Dementia Friendly environment is one of the key priorities for dementia care within the acute in-patient service at GWH. Evidence for change 1, 2, 3, 4, : The environment plays its part for patients with dementia/forms of cognitive impairment in a number of ways. Research suggests that if the environment is adapted to meets the needs of a person cognitively impaired the following outcomes are potentially achievable: 1. Less agitation and distress leading to lower usage of chemical restraint (sedation), increased autonomy and a more dignified care experience 2. Less agitation due to contrast colours on the walls (calming effect) 3. Less agitation due to simple and minimal signage/minimal information on the walls National Institute for Health and Care Excellence (2) Dementia: Supporting people with dementia and their health in Health and Social Care, Clinical Guideline No

2 4. Less agitation due to provision of orientation clocks and central point soft seating areas. Increased appetite, therefore a better nutritional input (with the use of coloured plates) and improved bowel function. Less agitation due to boredom (provision of meaningful activity ) 7. Drink fluids more often and remain hydrated (decreased risk of delirium) 8. Improved immune system function decreasing the likelihood of hospital acquired infection 9. Less risk of falls 1. Restorative sleep environment (Quicker recovery from illness/reduced LOS/Improved mental health) 11. More positive care experience/increased patient, carer and family satisfaction 12. Reduced need for close support (1-1 care) therefore increasing patient autonomy and promoting dignity in practice. 13. Potential to reduce costs (LOS/Close Support (1-1 care)/harm from falls/litigation) Methodology The data set is designed to track the impact of the environmental changes in the context of both the care pathway/journey, service impact and the in-patient experience. This will provide valuable data in relation to Safer Staffing mandate and provide evidence that may influence future service design and wider environmental changes (ward refurbishment programme). Pre and post opening data has been collated for Jupiter ward. Since re-opening in November 214 Woodpecker Ward has been used as a comparator for some elements as both clinical areas are Older Persons Care Wards (OPC) as there are no admission criteria differentials. Data is both quantitative and qualitative to create a multifaceted overview of impact. Data collected for this report is from mid-214 mid-21. Number of Discharges Number of patients discharged with diagnosis of dementia is increasing o o Total number discharged in 213/14 was 131, average of 113 patients per month Total number discharged in 214/1 was 14, average of 13 patients per month Correlates with projections of increasing number of dementia patients predicted in Swindon and Wiltshire 14% increase in number of discharges with dementia National Institute for Health and Care Excellence (2) Dementia: Supporting people with dementia and their health in Health and Social Care, Clinical Guideline No

3 Number of Discharges - Jupiter/Woodpecker. Since Jupiter has reopened as a dementia friendly ward in Nov-14 to Apr-1 o Jupiter has discharged 1 dementia patients, average of 17 patients per month o Woodpecker has discharged 92 patients, average of 1 patients per month Mean Length of Stay Mean length of stay for patients discharged with diagnosis of dementia is decreasing o Mean in 213/14 was 11. o Mean in 214/1 was 1.2 Decrease of.81 days Mean length of stay for patients discharged with diagnosis of dementia is decreasing, for Jupiter only o Mean in 213/14 was o Mean in 214/1 from Nov-14 to Mar-1 (after refurbishment) was 1.8 Decrease of.33 days It is important to view the data presented in the context of the following: Growing numbers of patients being admitted to Jupiter ward with dementia (See point 1) The streaming of less frail elderly patients to Kingfisher Older Persons Short Stay Unit (KOPSSU) changes the demographic on Jupiter ward to an entire cohort that is made up of frail, elder patients with multiple comorbidities and complex social care needs. PHARMOLOGICAL INTERVENTION FOR AGITATION Sedative medication can be used for a variety of clinical situations, not just agitation. It is not possible to extract data in relation to reasons for use, however the new electronic medicines administration system (EPMA) may allow this for future reports. Important caveat: Data collected is based on totals of medication ordered, not totals administered but this data suggests that the use of medication to support agitated patients is decreasing on Jupiter ward. End of life sedation (EOL): Usage suggests the numbers of patient on Jupiter receiving EOL care is increasing supporting the data in relation to the increase in fragility of patients admitted to Jupiter 2 1 Midazolam mg/1 Vials per box 1 Midazolam mg/1 Vials per box National Institute for Health and Care Excellence (2) Dementia: Supporting people with dementia and their health in Health and Social Care, Clinical Guideline No

4 Hours Medication for sedation: Jupiter has not ordered any Haloperidol for the past months suggesting a decrease in the need to prescribe for extreme agitation 1 Haloperidol mg/1 vials per box Haloperidol mg/1 vials per box Medication for sedation: Data suggests less Lorazepam has been dispensed since Nov 14 suggesting a decrease in the need to prescribe for extreme agitation Lorazepam 1mg/28 tablets per box Lorazepam 1mg/28 tablets per box CLOSE SUPPORT Close Support is provided to patients who are assessed as being at risk to self and/or others to a point that they cannot be supported safely without the provision of extra staff over and above the ward establishment WTE. The provision of Close Support (1-1 care) is costly and not provided for within the current budget structure. The reopening of Jupiter coincided with the launch of the new Close Support process and documentation. The data suggest that Jupiter is maintaining a lower level of close support requirement despite increasing numbers of dementia patients. Jupiter Ward Close Support hours per month + Numbers of patients with dementia discharged from Jupiter ward May 14 - May May June July Aug Sept Oct Nov Dec Jan Feb Mar April May Total Hours assigned No's discharged patients National Institute for Health and Care Excellence (2) Dementia: Supporting people with dementia and their health in Health and Social Care, Clinical Guideline No

5 FALLS Narrative Falls cost lives and adversely affect the quality of lives. Falls cost the NHS 2.3 billion per year or 92, per average acute 8 bed hospital (Exc. Litigation costs) and an average of 1,21 per patient excluding costs of extended rehabilitation and social care The human cost is less easy to quantify but is likely to result in pain, distress, injury, loss of confidence and independence to the patient and anxiety and distress to relatives, carers and staff. Prevalence:.4 incidents per 1 acute bed days (Average). It is important to view the data presented in the context of the following: Growing numbers of patients being admitted to Jupiter ward with dementia (See point 1) The streaming of less frail elderly patients to KOPSSU The data suggests the following: Despite the numbers of patients admitted with dementia increasing there is a current downward trend in relation to risk of falls on Jupiter ward There is a current downward trend for patients with dementia to fall on Jupiter ward At an average cost of 1,21 per patient (Excluding rehabilitation and social care costs) this trend could represent a significant long term cost saving for the Trust Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-1 Feb-1 Mar-1 Apr-1 Falls - dementia Falls other reasons TOTAL Total Falls Average Upper Control Limit LCL National Institute for Health and Care Excellence (2) Dementia: Supporting people with dementia and their health in Health and Social Care, Clinical Guideline No

6 Numbers of complaints by month PATIENT EXPERIENCE COMPLAINTS Jupiter Ward has been supported through a programme of transformation underpinned by a comprehensive ward improvement plan which commenced towards the end of 213. The leading complaint themes at the start of the programme were standards of clinical care (Including poor staff attitude), and discharge planning. Complaints requiring a formal response have lessened considerably since the team undertook the programme. Concerns in relation to staff attitude have ceased to be an issue Mar - June 214 COMPLIMENTS Friends and Family feedback JUPITER COMPLAINT TRAJECTORY July - Oct 214 Nov 14 - Jan 21 Feb 1 - April 21 Jupiter % positivity rating (April 21) Snapshot of results - Narrative 22 3 th April 21 I am very happy with my treatment. The staff are very kind and look after me well. I have to be in a side room but I do not like it. Staff good and caring. Food needs to be vastly improved. The staff care is excellent everybody very helpful and nice. The staff have been great with my mum especially I would like to mention Dave, Claudia and Anne. They have gone above and beyond their duties. They deserve recognition and are an asset to the NHS. My care has been very good. The staff are very friendly and helpful. All the staff are very caring and personable. Noise level reduced i.e. Buzzer turned off more quickly. Difficult with the Hustle and Bustle of coordination staff to cover all areas of care. Friendly helpful staff. Staff were careful and supportive but there was a shortage of staff. The treatment received was good. Friendly staff. Modern environment. Friendly staff and very caring. Very well looked after no problems at all. Very good staff and helpful. Always treated with dignity and a smile. National Institute for Health and Care Excellence (2) Dementia: Supporting people with dementia and their health in Health and Social Care, Clinical Guideline No

7 Difficult to find staff as no central hub or reception. Difficult to get onto ward on the evening. Kind staff who listen to my wants and needs. Only improvement is more staff to patient ratio. Because the staff in this ward are all very caring people and serve a lot of respect. Reason for N/A above - who wants or intend to stay in hospital although the service is very often much better than in any hotel with your staff being more than helpful, lovely and professional. STAFF TURNOVER *ROLLING 12 month data OPC remains an area that is challenged to recruit and retain staff. Jupiter wards % need to be viewed in context with implementation of the transformation programme in 213 and the change of leadership. Most staff are recruited through the centralised recruitment process and are matched to vacancies. It is hoped that the opportunities for education and professional development now being offered in OPC (SCOPE/Close support programme) will serve to improve our recruitment and retention rates. Department Apr 14 May 14 Jun 14 Jul 14 Aug 14 Sep 14 Oct 14 Nov 14 Dec 14 Jan 1 Feb 1 Mar 1 Jupiter Ward - J % 34.48% 34.9% 34.9% 31.91% 32.1% 32.97% 37.% 39.2% 4.% 31.33% 2.29% Woodpecker Ward - J % 22.4% 2.3% 22.22% 21.% 23.38% 22.22% 2.83% 2.1% 24.72% 28.24% 27.9% Turnover: Data suggests Jupiter are starting to retain a greater number of their staff 4.% 2.%.% -1.% Turnover Jupiter Ward - J2 Woodpecker Ward - J314 Relevant data not included in the report: 1. Delirium Statistics in relation to rates of hospital acquired delirium rates are currently not collected or reported. This will be corrected once the Trust starts collecting this data to meet the Dementia CQUIN. It is anticipated this data will be collected from August Improved nutritional input Collection of meaningful data has proved elusive due to the multiple variables that go with weight loss and/or weight gain in a person receiving medical care. Work is on-going with the Trust dietetic department in relation to collating data however it must be acknowledged that measuring this element of care may not be possible Author: Wendy Johnson Matron OPC/Neurology/Stroke Services Unscheduled Care Directorate June 21 National Institute for Health and Care Excellence (2) Dementia: Supporting people with dementia and their health in Health and Social Care, Clinical Guideline No