The Royal Melbourne Hospital’s Dementia Pathway
The Royal Melbourne Hospital (RMH) received funding from the Victorian Department of Health to develop and evaluate a Dementia Pathway, with the aim to improve quality of care and outcomes for older patients with dementia.
This project began in 2014, and focused on the medical units as most of the hospital’s inpatients with dementia were admitted through these units. The first 12-14 months involved developing the pathway and implementation plan.
A literature review was conducted and interviews held with experts in dementia care and education, to identify best practice recommendations for caring for people with dementia in acute hospitals, and also barriers and enablers to implementation.
Local data was gathered to assess current practice and identify gaps by:
(i) mapping the patient journey using process mapping techniques and direct patient observation; and
(ii) conducting a staff survey and focus group with carers of people with dementia.
The lack of dementia education and training was identified as a key issue. In response to this a training day was held in February 2015 facilitated by the Dementia Behaviour Management Advisory Service (DBMAS) and Dementia Training and Study Centre (DTSC). This was followed-up by 4 case study discussions of recent patients from each of the targeted wards. 35 staff from the Emergency Department and medical wards attended the training day and 82 staff in total attended the case studies. Those who attended the training day were invited to contribute to the Dementia Pathway project as “Dementia Champions”.
Following the training day, the Dementia Pathway was implemented on the medical wards. It was piloted for 6 months (April-October 2015) and included the introduction of a Dementia Care Pathway document, the TOP5 and a new Behaviour Observation Chart. Dementia Pathway Resource Folders were developed and available on each of the wards; a Dementia Pathway intranet webpage and shared drive folder were also developed.
During the pilot phase project staff went to the wards most days to promote the pathway, explain how to use it to treating staff, and collect data on usage of the new forms (audit). Managers were sent the results of the audit. Project staff held information and promotion sessions about the pathway on each of the participating wards. Geriatricians and project staff also held education sessions about dementia and delirium. The role of the Dementia Champions was also to promote the pathway use and its resources, educate colleagues about best practice care for people with dementia, and communicate audit results and other project information to colleagues.
Following the pilot phase staff were surveyed and focus groups held to collect feedback on the Dementia Care Pathway and accompanying forms and implementation strategies. A medical record review is currently underway to assess processes of care and outcomes before and during the pilot phase.
Key strengths of the pilot phase:
- Approximately 20 Dementia Champions continue to be active on the wards – a passionate group of nursing and allied health staff. On one ward they conducted a short survey of knowledge and confidence in caring for people with dementia and delirium. This then resulted in Dementia Champions from two wards running in-service training on dementia and delirium to reach night duty and weekend staff.
- Most people surveyed were aware of the project’s implementation strategies. They were aware of the documents and had received information about how to use them from project staff or Dementia Champions, and had received feedback on audit findings.
- From the post-pilot phase survey: 47% agreed the project had improved their management of patients with dementia; 21% neutral; 32% disagreed.
- The survey and focus group revealed positive feedback about TOP5 and Behaviour Observation Chart – useful, easy to use and are now part of routine practice on 3 wards.
- Dementia, delirium and cognitive impairment awareness has increased including the use and documentation of these terms
Difficulties noted in the pilot phase
- Staff found the extra paperwork burdensome which resulted in poor completion rates at times.
- Despite the increase in education sessions conducted, many staff had not attended an inservice about best practice care of people with dementia.
- Staff still struggled with the management of behavioural and psychological symptoms of dementia (BPSD).
Where to from here?
Based on feedback from the focus groups, surveys and meetings with Dementia Champions, senior medical and nursing staff we will be:
- Writing up and reviewing formal policies and procedures on the care of older people with dementia, including those with BPSD as formal policies are accessible for all staff and are routinely updated.
- Identifying apps or web based guidelines and other tools for junior staff, and making these available on the intranet.
- Embedding some of the actions from the pathway into new daily Multidisciplinary Team ward rounds For example, inclusion of cognition and behaviour in the ward round checklist, informing carers of the time of the ward round and inviting carers to participate
- Continue to work with dementia champions & educators to provide ongoing, regular educational opportunities accessible for the range of staff.
Helpful hints for others
- Collect local data to reinforce the need for change.
- Take the time to engage with staff and consumers to identify current issues and possible solutions – e.g. direct patient observation, carer focus groups, process mapping.
- Appoint a person to coordinate the change process.