Royal Hobart Hospital

Our Initiatives

  • The adaption and introduction of a combined Mini-Cognitive test (quick screening tool for cognitive impairment) and the 3D-CAM (delirium diagnostic tool)
  • Branding delirium, so that it is visible e.g. stickers, alerts in clinical charts
  • The adaption of a behaviour assessment chart for acute care (ongoing)
  • The development of a Cognitive Champion education program targeting delirium assessment/ interventions (2 hour seminar, written package and coaching sessions)
  • Cognitive Champion education for key community groups e.g. ACAT and Community options case managers
  • Pre surgical screening for those at high risk of post-operative delirium; with a process to review modifiable risk factors and provide patient/ family education (Elective Orthopaedic and Cardiothoracic surgeries)
  • Family engagement and the provision of written and verbal information when delirium is identified and/ or where there are behaviours of concern
  • Family engagement in the documentation of key care/ communication strategies and identification of non-pharmacological strategies when there are behaviours of concern e.g. toy therapy
  • The Strengthening of an acute care link with the Dementia Behaviour Management Advisor Service (DBMAS) when clinical expertise or community follow up is required for behaviours of concern

What has worked

  • Engaging with clinical areas directly; using coding data and case studies to illustrate why they should care
  • Presenting staff education that details the human and financial burden of delirium, with examples from; coding data, clinical experience and specific financial data e.g. revenue loss from activity based funding or additional healthcare costs
  • Building staff confidence by providing practical information that breaks delirium down into understandable elements; explaining what they are seeing and discussing ways to engage with patients, educate family and communicate with medical staff
  • Providing Cognitive Champions with coaching on the 3D-CAM in clinical areas after an initial 2 hour education session
  • Having Cognitive Champions that are allied health or in key work positions e.g. The Emergency Multidisciplinary Assessment Team (EMAT)
  • Providing education to non-clinical staff e.g. AIN’s (patient safety observers) and allied health assistants
  • Working as a team e.g. Ensuring consistent practice within the Aged Services team, having the support of a Cognitive Care Working Group and Geriatricians
  • Using well researched tools and interventions based on best practice
  • Engaging with families; giving them the tools to say when they notice a change in cognition, and the permission to be actively involved in the patient’s recovery.

Challenges

  • Across all disciplines there is a persistent lack of understanding about what delirium looks like e.g. drowsiness is not normal, and its associated poor outcomes
  • The time pressures of nurses in ward areas
  • Balancing a clinical workload and project work that requires culture change
  • The need for maintenance education to continue the momentum of early culture change

Outcomes

  • Regular monitoring of coding statistics indicates the identification of delirium is improving across all medical/ surgical/ speciality areas
  • Anecdotally there is a positive response from patients/ families about being given information and the permission to help
  • After education and coaching, staff feel more confident in the use of screening tools
  • A gap analysis was completed to compare the Royal Hobart Hospital’s current practices with “A better way to care”.

Where to from here

  • Ensure all clinical staff have access to education and resources, with clearly defined roles and responsibilities
  • Through partnering with the national Dementia in Hospitals Program, ongoing improvement of current systems for the early detection of cognitive impairment that trigger key interventions
  • Ongoing review and improvement of current practice around the assessment and management of behaviours of concern
  • Ensure staff are aware of their role and responsibilities in the communication of cognitive impairment during transitions in care, and the pathways for community follow up are clearly defined
  • Through the provision of information, further develop a more sophisticated partnership with families’ e.g. promoting an advocate role within the community and acute care.