Transforming Dementia Care within Royal Cornwall Hospital Trusts

1. Transforming Dementia Care within Royal Cornwall Hospital Trusts Dr Fiona Boyd, Dementia Lead. Bev Chapman, PCT Lead Maggie Trevethan, Clinical Nurse Lead

2. Past ,Present and Future • Service development to date • Ongoing projects • Our vision

3. To date. • Ongoing over 5 years • Shared care philosophy • Designated clinical lead • Designated ward base • Collaborative working

4. Long Term Condition • Diagnosis • Maintenance • Complex • Palliative

5. Bed base 588 nTD = 69 (11%) nDementia=57(10%) nDelerium=9(1%) Bed base 538 nTD=74(13%) nDementia=57(10%) nDelerium=17(3%) Dementia Mapping - Comparison figures 2006-2008

6. Correlation between delay in discharge and those patients with cognitive impairment • A direct positive correlation between delay in discharge and those patients with cognitive impairment who demonstrated evidence of disability. 2008

7. 66% of these patients are located within the Medical Directorate. • 45% of all cognitively impaired patients in RCHT Eldercare setting • 30% individuals - ‘bed-blocking’ whilst they awaited discharge from hospital to care home environments.

8. The RCHT Memory Service provides • Diagnosis (with a front door service) • Rapid access to investigations and assessments • Designated ward with specialty trained staff • Guidelines and Care Pathways • Supervision & reduction in prescribing(sedation &antipsychotics) • Patient and Carer support • Improved Awareness and Education

9. Guidelines Dementia Acute Confusion Palliative Care Pain management Mental Capacity Anti-psychotic prescribing DOLS Pathways and other Behavioural Chart and assessment tools Cognitive assessment tools PAINAD Carers support Life story books Communication Alert scheme Guidelines and Pathways

10. Education and Awareness • Local to RCHT: • Training F1/2, GP AND Specialty registrars trainees • PMS • Mental Capacity • DOLS • ‘Lets respect’ -DoH • Competency Training for Nursing staff and allied specialties • Patient and Carers forum

11. Education and Awareness • Regional: • Annual Eldercare Good Practice Day 2004-07 • Dementia Away Day 2006 • Lets Respect RCH(CIPS-Plymouth 2007) • Hospice Staff training 2008/09 • Gp training day 2008/09 • Community Matrons 2008/09 • Dementia Academy 2009 • Worried About Your Memory (Alzheimers Society 2008-9) • BBC Radio Cornwall Phone-in (2008/09)

12. Education and Awareness • National: • RCN: The Journey End –approach to palliative care (Cardiff 2007) • RCN :Lets Respect –Communication Alert System( Edinburgh 2009) • National Palliative Care Conference (7th): Palliative care in Dementia (Glasgow 2008) • Psychiatry & Mental Health –Communication Alert Scheme (Leeds 2009) • RCN: –Communication Alert Scheme–(Edinburgh 2009)

13. OPMHG -Cornwall Participation in Developing Cornwall Strategy Regional Audit Other Related Activities

14. Joint PCT/RCHT Audit of Nursing Home Admissions Dr Fiona Boyd Bev Chapman Kylie Cook Maggie Trevethan

15. Aims • Retrospective Audit • Admissions involving NH • Identify the appropriateness of the admission with a view to developing pathways to reduce admissions and facilitate more effective patient journey

16. Reference details: Audit number NHS Number: Care home: Sex Age Time of admission DOA DOD LOS Referral source: GP/ A& E SB GP yes/no Ward allocation(s): 1 2 3 4 Reason for admission: Diagnosis (es) 1 2 3 4 Prescribing issues: Yes /No If yes, comment: Nursing needs: Yes/No If yes: date of request date actioned Review date Delaying factors Place of discharge Possible alternatives to admission

17. Provisional Data Jan-March 2009 • Total Number Admissions 91 • Length of Stay 1421 bed days • See by GP before admission 27 (30%) • Required admission 10 (37% of reviews; n/11% ) • Seen ‘Out of Hours’ 59%

18. Breakdown of Admission Types

19. ‘Other’ • General breathlessness – fatigue/exhaustion/SOB (12%) • Admission from CPT • Step up care (4%)

20. Other important Findings • Palliative 29 (32%) • Treatment feasible in the Home 64 (70%)

21. What’s Next? • Analyse all data and correlate results • Clear patterns: End of Life Care Appropriateness of Admissions Links with Advanced Planning for End of Life Care & review of community care

22. Guidelines: Dementia • Section 1 Dementia Pathway Summary • Section 2 What To Do on Admission and Why. • Section 3 How to Manage Difficult Behaviours. • Section 4 Dementia Assessment Tools and Care Plans • Section 5 Discharge Planning and Who To Contact. • Section 6 Assessing Capacity. • Section 7 Contact List of Community Mental Health Teams • Section 8 Appendices of Assessment Tools and Care Plans

23. Cognitive deficit identified: Chronic / Acute on Chronic / Acute Diagnosis Dementia Known SuspectedDementia History Check who made diagnosis and date Examination Does history include: Deteriorating cognition Challenging behaviour Complex discharge No No Psychiatric input needed discharge as per medical needs Investigations Cognitive Assessment Yes Is deterioration rapid and unexplained? Yes Identify and Treat reversible factors No Contact Eldercare team for definite diagnosis Nurse in a Calm Quiet Environment For details of above flow chart see following page No Any psychiatric concerns? Risk to others / self? Yes Contact eldercare psychiatric liaison teamvia switchboard If unavailable contact on call mental health services on ext 1300 Consider using section 5(2) Mental Health Act if necessary Using monitoring tools (see section 4) and sedate as necessary Use sedation if necessary. Adjust dose according to body mass and renal function. Review daily. Only if severe distress or there is an immediate risk of harm to the person with dementia or to others.

24. 24 hour behavioural chart

25. Guidelines : Pain • > 50% of elderly suffer from painful conditions • Pain control is frequently inadequate. • Demographic shift –increase in elderly population • The number of patients with dementia who will experience pain is likely to increase.

26. Patients with Dementia • Experience communication difficulties • Lack understanding • Interpret and express their pain in ways

27. PAINAD

28. Guidelines: Palliative • Understand the drivers to improving end of life care for those with dementia • Identifying terminal phase care • Practical measures (care pathways)

29. Key Aims: • Determining whether someone is ‘end stage’ – using clinical diagnostic indicators and specialist support. • Identifying the patients needs (physical, psychological, behavioural) • Identifying and managing symptoms • Support to carers and families.

30. Best Practices covering: • Pain Assessment (reference to Pain Pathway) • Airway toileting and respiratory symptoms • Physical hygiene • Nausea • Mouth care • Tissue viability • Bowel care • Pastoral & Spiritual support.

31. What on For 2010 • Re-launch –Let’s Respect campaign in collaboration with ‘Worried About you Memory’ • What’s Your Story- Life Story Books • Education -Modular programme (In collaboration with Learning Development) • Completion of RCHT Dementia Strategy and Business Plan

32. Our Vision • Countywide Education Program (NVQ Training and diploma status – County Wide resource) • Countywide Network Forum • Link Nurses for Dementia –RCHT • End of Life –advanced planning

33. In Summary There is excellent leadership and ownership in advocating for dementia care in RCHT allowing multidisciplinary assessments and shared care with the psychiatric liaison services. Continuous drive to improve quality of care

34. The Royal Cornwall Hospital People with passion and vision.