Monash Health*

The Delirium and Dementia Initiative at Monash Health

Introduction

Monash Health has embarked on an ambitious initiative to improve the early recognition of and response to patients with cognitive impairment (delirium and dementia) in acute and sub-acute services, ensuring these patients receive safe and high-quality care in hospital. Based on the work of the Care of Confused Hospitalised Older Persons (CHOPs) program in NSW, the initiative covers all elements of cognitive care, from screening and assessment through to management and discharge planning. It is supported by a comprehensive staff education program and the appointment of a Cognition Clinical Lead.

Issues/ problems faced

Cognitive impairment in hospitals is not seen as a ‘glamour’ issue when it comes to innovation and improvement priorities, so one of the first challenges was getting an organisational commitment to addressing the issue, and providing resources to support an effective solution. And the commitment had to be long-term (minimum 2 years) as we knew there was no simple or short-term fix.

The next challenge was the stakeholder engagement to determine what our implementation was going to involve and then tailoring the program to various clinical areas.

Our final problem will be maintaining the momentum.

Strategies that made (or could have made) a difference to your experience

There is no shortage of resources to support best care for patients with cognitive impairment so we were conscious of not re-inventing the wheel. Various organisations have been very generous in sharing their knowledge and learnings with us, namely those involved in the CHOPs Program in NSW and the Environmental Design Education Service within Dementia Training Australia. But we also had to tailor the solution to our setting. We undertook extensive planning and wide-ranging stakeholder consultation, which is paying off now in our implementation phase.

Tips for others

  1. Take a long-term view – improving care for patients with cognitive impairment in hospitals cannot be fixed with a short-term solution
  2. Ensure you have as much executive-level support as you can muster – appeal to both the hearts and minds of your stakeholders
  3. Partner with your front-line clinicians – they are the people who know best what the problems are and what the solutions could be
  4. Invest in education for staff – make sure it is fit for purpose, accessible and relevant
  5. Celebrate your success and learn from experiences that don’t get the results you wanted

Outcome

We have just started our implementation journey – starting with the General Medicine wards at our largest campus. The staff experience of implementation has been very positive, and the staff have valued the support of the Cognition Clinical Lead (a new role for our organisation). Education has been well-attended and online resources have been accessed by large numbers of staff. Staff are now:

  • actively screening for cognitive impairment in admitted patients over 65yrs using the 4AT
  • taking active steps to both prevent and manage delirium
  • using tools like the Sunflower and TOP 5 to get to know their patients and their families better
  • accessing education and assistance from our Cognitive Clinical Lead and our online education modules to help them better care for patients with cognitive impairment
  • educating families and carers about delirium and dementia management, prevention and expected outcomes.

Compliance rates with cognitive screening have been very high, nearing 100%, and falls and Code Greys appear to have reduced in this cohort.

We are about to start Phase 2 implementation at our subacute campus.