Princess Alexandra Hospital (PAH) is a large tertiary referral hospital in Brisbane. Over the past decade various services, wards and units at PAH have implemented quality improvement processes for the care of cognitively impaired patients, culminating in the provision of innovative nursing resources and models of care. While further work is required, our journey started small and has progressed to its current phase of hospital-wide consolidation.
The Journey:
- In 2006, our internal medicine unit (IMU), comprising 3 wards, undertook research on introducing evidence-based dementia care into clinical practice through local education strategies. Amongst other initiatives, a “Sunflower Chart” was implemented to facilitate person-centred communication using biography. Outcomes demonstrated improved person-centred care, zero-restraint use and improved medication safety.
- At the same time, a hospital-wide geriatric consult service (GATE) was implemented, providing a one-stop-shop for geriatric triage, advice and aged care assessments (ACAT). While this delivered an efficient, integrated consult service for older patients throughout the hospital, it also provided an important fail-safe to reduce risk of inappropriate discharges for people with cognitive impairment (i.e. delirium diagnosed as dementia) and provided expertise around differential diagnosis in syndromes involving cognitive impairment.
- In 2008, responding to increasing prevalence and adverse outcomes, the IMU implemented an 8-bed high care unit for cognitively impaired patients experiencing high-risk behaviours related to delirium and responsive behaviours in dementia . Although environmental modification was minimal and the unit was not locked, positive outcomes demonstrated a 30% reduction in falls for cognitively impaired patients and 62.7% reduction in nurse-specials across the IMU.
- Various recreational and clinical resources were developed alongside an innovative behavioural observation chart that records aggression, agitation and sleep while also incorporating a verbal pain scale and the PAINAD. This facilitated clinical evaluation of symptom responses to care interventions such as toileting, recreation, socialisation, exercise, medication administration and an evidence-based approach to assess pain in cognitive impairment (i.e. evaluation of analgesic trial). The chart was adopted across the hospital and is now a state-wide Queensland Health form.
- PAH has provided a clinical nurse consultant (CNC) for dementia and delirium since 2009 working across the hospital, undertaking clinical consultancy alongside facilitation of organisational change, workforce preparation, education and research. The role implemented a hospital-wide mandatory nursing education package comprising written modules, interactive workshops and training for the Confusion Assessment Method (CAM).
- Through the education roll-out, a network of over 120 change champions were recruited known as CogChamps. They established prominent “cognition corners” in their local nursing stations, providing staff with immediate access to clinical tools such as the behavioural observation chart and resources for engaging patients in recreation, exercise and social activity. They also became valued local experts.
- Volunteer services were engaged to make fiddle blankets, indwelling catheter (IDC) decoy aprons, other comfort clothing and resources. Moreover, volunteer programs to assist people with cognitive impairment were commenced in orthopaedics and the IMU. These volunteers engage cognitively impaired patients and older patients at risk of delirium in conversation, recreation and socialisation.
Recent work:
- Research into whether senior CogChamps could improve the quality of care for people with cognitive impairment through a collective social education approach was undertaken in 2015 – 2017. Outcomes demonstrated a sustained increase in cognitive assessments and identification by nurses plus improved pain management. Other care outcomes were not statistically significant; however, this may have been due to methodological issues. The research could report a clear increase in staff awareness and development of localised resources.
- The CNC Dementia and Delirium recently contributed as a principle content author to the “View from Here”, a peer-reviewed online education package for acute care nurses developed by Dementia Training Australia (DTA). Now available for all acute care facilities in Australia through the DTA website, PAH made this mandatory training for all inpatient nurses. The “View from Here” is described in the Australian Journal of Dementia Care.
- Recently, PAH went fully digital. A concerted effort was made to include nurse risk-screening processes for cognitive impairment and to incorporate a delirium screening tool – CAM. The behavioural observation chart was also converted into an appropriate digital format and placed into the digital workflow.
- PAH has also attempted modifying some aspects of the physical environment. The recent development of a community garden has led to increased opportunity for social and recreational activity for cognitively impaired patients. In the IMU, the provision of contrasting toilet seats maximises patient independence around toileting.
Where to from here:
Major projects now involve further work at the local unit level, staff preparation and digital hospital design.
- A second delirium screening tool, the 4AT, is being designed into the digital system. This work is being undertaken between digital hospitals at a state-wide level. The 4AT arguably requires less hospital-wide effort in training than the CAM. The CAM will remain in the system as well.
- IMU continues to develop innovative simulation training for managing symptoms of cognitive impairment using role play and case study analysis. Recent skills training has extended to physical handling techniques for physical aggression involving 4hr-training sessions for all nursing staff using a Maybo trainer. This has improved staff confidence and provides a safer situation for staff and patients alike. It also addresses a growing concern in the workplace around occupational violence
- ICU is currently reviewing their management of delirium which includes environmental initiatives and an update of the guideline to reflect best practice. This is a quality improvement project involving the whole nursing, medical and allied health ICU team.
- Initial work has begun exploring how nurse specialling across the hospital can refocus from a custodial approach to a therapeutic one and build upon foundational knowledge and care practices we have been training our nurses.
Helpful Hints:
- Start change in units and with clinicians who are already enthusiastic and interested. Success in these units, tends to lead to interest from other units
- Promote the Comprehensive Care Standard to build awareness and interest
- Once appropriate clinical tools and system design are in place, use localised champions for effective practice change
- Start small and celebrate your successes
- When using a specialist nursing role to facilitate change, be realistic about the role to avoid burnout. The role is likely to work best within a geriatric service structure.
