Barwon Health University Hospital is situated in Geelong, in the south-west of Victoria, and provides acute hospital and emergency department services.
Our initiatives and outcomes so far
Screening for cognitive impairment
At Barwon Health University Hospital Geelong, an electronic assessment system is in place, including the abbreviated mental test score (AMTS) to assess cognitive impairment. AMTS completion rates are monitored by a Cognitive Impairment Improving Clinical Care Committee and are gradually improving.
Assessing for delirium
- If a patient has an AMTS of less than seven on admission, a referral for a confusion assessment method (CAM) is required.
- The single question in delirium (SQUID) is used as part of ongoing reflection, reassessment, clinical communication and discussions with families. It there is doubt around a change in cognition, the patient is managed as though there is delirium. (Identify cause, seek assistance, and treat causes.).
- The Calvary agitation scale is being used in a key clinical area. Evaluation of the agitation scale resulted in recognising the need to recommence a refreshed rollout of cognitive care, possibly every 1 to 2 years, until cognitive care is a ‘natural’ way to practice.
Preventing falls and pressure injuries
Pressure injury risk assessments and falls risk assessments occur on admission. Completion rates, the quality of assessments and how information from assessments is used in planning care are discussed and audited. Education activities include providing hints for improving assessment and prevention plans.
Interventions to prevent delirium
- Barwon Health’s Cognitive Care forms the core of the clinical practice being developed, and includes risk assessment of cognition, pressure injury and falls, as well as involving the patient and carers to prevent distress and identify and address issues.
- CAUSED (communication, activities, unmet needs, social issues, environment and/or the dementia) outlines the method used for problem prevention and management, and to analyse issues. Forget-me-nots are used to prompt conversations, and include information on what may cause distress and/or provide reassurance.
Identifying and treating underlying causes (of delirium)
- An annual education plan is provided to reduce unwarranted variation in clinical practice with regard to cognitive care including the recognition and management of delirium. The rate of delirium, as an acquired complication, is monitored, and a plan to address under-coding of delirium is being considered.
- In 2016 a major audit was conducted to enable the analysis of unwarranted clinical variation with regard to cognitive care and the prevention and management of delirium.
Minimising use of antipsychotics
- Guidelines have been developed to support eliminating unwarranted use of antipsychotics in elderly patients. Education sessions have been provided for medical, allied health and nursing staff.
Goals of Care and Transition from hospital
- Consideration of transition planning is promoted through guidelines and education activities, and through advice from geriatric medicine, the Dementia Behaviour Management Advisory Service (DBMAS) and transitional care. A project has commenced to identify patients’ values as part of discharge planning.
- The identification of advance care plans, and recognising the special requirements of people with cognitive impairment is also being promoted.
- A delirium pamphlet developed by the Victorian Government will be expected to be provided to all people experiencing delirium. At present this is provided when the patient, with a diagnosis of delirium has been seen by Geriatric Medicine.
Establishing responsive systems
Clinical leadership is provided by the Director of Aged Care and other geriatric medicine specialists. The Cognitive Impairment Improving Clinical Care Committee has overseen the development of documented guidelines for:
- Cognitive Care including escalation of care
- Use of the cognitive impairment identifier
- The agitation scale
- The single question in delirium – SQUID (Does the patient seem more confused to you lately?)
- The CAUSED method. This includes multilingual cue cards, signs and forget-me –nots, use of activities, planned exercise, adjustment to the environment/equipment
- An intranet site to support practice and education.
Information is being developed to support the establishment of a cognitive liaison clinician to fully engage and develop the capacity of acute staff in the care of patients with cognitive impairment. For Cognitive Care to become a genuine and reliable practice, positive reinforcement of learning, real time practice support and the development of more advanced skills are required.
Ensuring a skilled workforce
- Clinical guidelines are available on an electronic policy and procedure system.
- Cognition Champions are led by nurse educators, who aim to hold regular cognition champions forums – support sessions.
- Dementia and delirium clinical skills workshops and sessions are conducted for nursing medical and allied health staff.
- Barwon Health Volunteers participate in education provided by Alzheimer’s Australia.
- Top Tips are monthly one page updates on Cognitive Care including consent, advance care planning, activities, and hints on how to better involve the family.
- An intranet provides multilingual resources, links, presentations, minutes of meeting, Top Tips and toolkits.
- The Barwon Health Cognitive Impairment: Improving Clinical Care Committee includes representatives from Alzheimer’s Australia, DBMAS, advance care planning and a consumer representative.
- A carer information sheet also promotes the development of partnerships.
What has worked?
- Clinical leadership
- Formation of the Cognitive Impairment: Improving Clinical Care Committee with its broad representation
- Education plan
- Embedding tools in the electronic system
- Need for a continuous, supportive approach in engaging staff and maintaining and developing skills and confidence.
Where to from here?
- Continue initiatives
- Promote the ‘knowing about me’ program (to supersede Top 5 Handy hints)
- Consider appointing a cognitive liaison clinician
- Possible plan to address under-coding of delirium
- A continuous and supportive approach to engage staff in reliably recognising and responding to dementia and delirium.