Implementation of 10 Dementia Care Actions
Our objectives for the next 3 years identify key parts of the national actions that we plan to take forward. Work is also ongoing in relation to the other national actions.
Identify a leadership structure within NHS Boards to drive and monitor improvements
NHS Golden Jubilee has a clear leadership structure in place.
The Executive Nurse Director is the Board leader for Dementia Strategy.
The Associate Nurse Director (corporate) provides operational support and leadership to the Lead Dementia Nurse, a role which has been re-established within the organisation.
The Lead Dementia Nurse aims to enhance and nurture the Dementia Champions leadership role to support clinically based teams. In addition, Registered and Non-Registered practitioner roles will be developed to support clinical care of the highest quality of dementia care.
Develop the workforce against the Promoting Excellence Framework
A dementia education matrix (Appendix 2) has been developed to support knowledge and skill progression for clinical and non-clinical staff. This will maximise the scope and opportunity for all levels of clinical and non-clinical staff to help optimise their ability and confidence to care for people with dementia.
The use of this matrix is consistent with national work, as it has been adopted by all NHS Scotland Boards via Alzheimer Scotland Dementia Consultant Group to help structure and define educational framework for each Board.
Plan and prepare for admission and discharge
The majority of care delivered at GJUNH is planned / scheduled care.
Many people who are living with dementia attend pre-admission clinics which facilitates effective planning care for their admission. Families/carers of patients with dementia and vulnerable adults are asked to fill in the “Getting to Know Me” document (Appendix 3) and to bring this with them on admission. This document provides all staff with details to support person centred care planning and to assist when patients have difficulty communicating their needs. Any additional support needs are also explored in clinic and accounted for in care planning when admitted.
We are reviewing all assessment documentation to ensure it remains fit for purpose. Any potential changes will be discussed and approved through the senior nursing groups governance structure in accordance with any recommendations identified.
The Lead Dementia Nurse, in conjunction with national Alzheimer Scotland Dementia Consultant Group, will communicate and highlight any developments or approved improvements in assessment and documentation systems across Scotland for consideration at NHS Golden Jubilee.
Delirium information is provided at pre-assessment clinics. We will review and develop screening systems that are sensitive in identifying and helping manage patients with higher risk of experiencing delirium during hospital admission.
Proactive discharge is the main guiding principle from pre-admission to ensure safe and timely discharge. Specialist Discharge Team support clinical teams working in partnership with carers and external agencies throughout pre-admission and during any hospital stay.
While most of our clinical activity is planned care, there is also emergency and urgent care within our heart and lung services. Standardised tools to recognise and facilitate effective person centred management of delirium are used on admission these areas to provide early detection of cognitive impairment. Like planned care, training needs analysis will be carried out to identify priority areas.
Develop and embed person-centred assessment and care planning
Using the ‘Getting to Know Me’ document, and working with the person living with dementia and their carers, allows staff to develop individual care plans. The updated version following national review is currently being implemented across the hospital. Use of “What Matters to Me” (WMTM) boards also supports the provision of person-centred care. Full compliance with WMTM boards.
enhances provision of all patients care but is of particular benefit for people who have a dementia. The importance of individualised care is also emphasised within training materials and sessions provided.
Audit of documentation systems will be undertaken as a care assurance mechanism to ensure good practice is embedded and understood in care provision for people with dementia.
Promote a rights-based and anti-discriminatory culture
The Charter of Rights for People with Dementia and their Carers, Scottish Government (2009), sets out the right of people with dementia to continue to receive equitable care and not to be excluded based on their diagnosis. This is promoted throughout the hospital by the Lead Dementia Nurse, Dementia Champions, clinically based Link Nurses and through training materials.
Audit work will be undertaken to monitor appropriate use of the legal framework to ensure people with dementia are protected at all times.
Develop a safe and therapeutic environment
All relevant policy and guideline development will include review and recommendations from the Lead Dementia Nurse.
The Lead Dementia Nurse will advise the Safe Mobilisation Group and will review any relevant policies or guidelines (e.g. Guidelines for Increased Intervention for Patients with Altered Cognition). The underlying principle is that all policies and guidance will be consistent to ensure that support of people with dementia will receive specialist therapeutic input as well as protecting core safety.
Review of current therapeutic resources will be undertaken and systems re-established to provide resources such as a CD player, CDs, playing cards and puzzles.
In addition, a nationally available resource: “Pocket Ideas and A Moment in Time” a booklet which is available and provides topics for conversation and suggested activities to support staff to communicate with people living with dementia. We plan to increase awareness and availability of this booklet to staff as a useful resource.
“Twiddlemuffs”, which are used to calm and distract patients from removing devices, are also available. Further resources will continue to be explored.
Significant work has been undertaken to ensure that the relevant clinical areas in the phase 2 hospital expansion are dementia friendly.
There has also been focussed input to optimise the environment in the Eye Centre.
While previous assessments and actions have been taken to help ensure the entire hospital is dementia friendly, there is a need to revisit and review clinical and relevant non-clinical areas such as hospital entrance and corridors between departments. A dementia-friendly environment programme is under way to review and assess these areas to help maximise a safe and therapeutic environment for people with dementia.
A recognised tool developed by The King’s Fund, ‘Is your hospital dementia friendly’ is being used to support this programme (Appendix 4) The audit process includes Alzheimer Scotland, person with lived dementia experience, Estates Department, clinical staff and the Service Design and Equalities Lead.
A report with recommendations will be generated for each area. This will then be discussed with appropriate operational and / or management teams and any agreed actions will be progressed.
Use evidence-based screening and assessment tools for diagnosis
The Abbreviated Mental Test 4 (AMT-4) is used for all patients over 65 attending for pre-assessment and on admission. Although a limited tool, it can assist in identifying cognitive impairment and trigger more in-depth screening and investigations.
The 4AT (Arousal, Attention, Abbreviated Mental Test and Acute change) is a rapid clinical assessment for delirium (Appendix 5), which includes the AMT4, and the Confusion Assessment Method for the Intensive Care Unit (CAM ICU) (Appendix 6) are used to identify delirium and trigger the implementation of the TIME Bundle for early recognition and appropriate management of delirium (Appendix 7). This helps identify interventions to treat and support patients who have developed a delirium.
The use of these tools is regularly audited and actions assessed.
It is recognised however, that the current systems may not adequately identify people at risk of developing a delirium during hospital stays. Quality Improvement projects are being carried out to assess whether current screening arrangements are appropriate for patients with cognitive impairment.
A Hospital Delirium Group will be established to help support best practice, develop consistent approaches and review use of available assessment tools. The Lead Dementia Nurse will chair this group.
Work as equal partners with families, friends and carers
The currently used Carers Information Leaflet to reflect The Carers (Scotland) Act 2016 is under review. Posters are on display throughout the hospital welcoming carers to identify themselves to staff and to be involved in patient care.
The Lead Dementia Nurse will be working with local Alzheimer Scotland resource team to provide appropriate accessible and helpful information in all clinical areas and assessing the need to establish (I think there was but unsure of how well established so on balance best to state as new initiative) Carers Forum. This information will help provide access to community specialist support services for carers and patients.
Education resources will include importance of effectively communicating and always working in partnership with carers.
Person centred visiting is embedded. This helps empower carers to maximise working in partnership with clinical teams to meet individual patient needs.
Minimise and respond appropriately to stress and distress
Effectively managing and supporting patients with stress and distress related to dementia and delirium is challenging. The Lead Dementia Nurse will continue to work to improve this by providing training to support implementation of the recently revised Guidelines for Increased Intervention for Patients with Altered Cognition (Appendix 8).
The 4AT rapid clinical assessment for delirium and TIME bundle delirium treatment plan are core assessment tools designed to detect and treat clinical condition that may manifest itself as stress and distress. Implementation of these guidelines is monitored by the Lead Dementia Nurse and Clinical Nurse Managers.
Other measures already in place include pre-admission planning, dementia friendly rooms, a flow system in the Eye Centre, and a culture of encouraging carer partnership. These all contribute to help reduce stress and distress for patients.
As highlighted in Section 6, resources for social activities are available for people experiencing distress and delirium. Staff are advised on how to access these at any time of day or night.
Updated guidelines emphasise the importance of quality interaction when supporting patients who require enhanced observations due to stress or distress.
The Clinical Governance department will continue to review incidents reported through the DATIX adverse incident reporting system. This information will be used to identify learning needs to ensure the safety of both patients and staff. Scottish Intercollegiate Guidelines Network (SIGN) Delirium: prevention, diagnosis and management in hospital and long-term care (Last updated January 2023) are incorporated into practice across the Golden Jubilee University National Hospital.
The national dementia improvement portfolio within Healthcare Improvement Scotland (HIS) is a national work stream related to Stress and Distress in Acute Care to help support improvements in care in acute general hospitals and dementia units. The Lead Dementia Nurse works in conjunction with National Alzheimer’s Scotland Dementia Consultants Group to help coordinate implementation of this across NHS Scotland.
Evidence the impact of changes against patient experience and outcomes
NHS Golden Jubilee delivers care through collaboration and has a long history of leading the way in research and innovation.
The focus for improving dementia care will be consistent with this ethos.
The primary mechanism for changes will be through pursuit of quality improvements which will be on varying scales from small quality improvements using the Plan, Do, Study, Act model to more extensive projects. We expect that this approach will be an ongoing driver to change and improve aspects of care.
There are currently 2 quality improvement projects being carried out.
Project 1 is reviewing cognitive impairment assessment processes. The aim is to achieve robust reliable systems which will reduce the risk of patients developing delirium during hospital admission. The rationale is that early detection will help influence and determine appropriate care. This is being led by a Clinical Psychologist with the Lead Dementia Nurse participating and advising.
Project 2 is looking to find improved systems to identify and treat emotional disturbance and help distinguish between dementia, delirium and depression. This is being led by a Clinical Psychologist.
All patient and carer feedback in relation to dementia-related care is encouraged through internal and external systems. Improvements to care would be adopted and learning from this feedback.
The dementia friendly environment programme will actively engage with patients and carers to support better access and usability for service users.
The Lead Dementia Nurse liaises with Clinical Governance to support learning and improvements from any complaints and incidents logged in Datix.
