High Impact Change Area E: Improving the inpatient experience

Setting out the challenge

Evidence indicates that, at any one time, people with dementia occupy 25 per cent of acute hospital beds, stay in hospital twice as long and are admitted for infections treatable in the community (RightCare dementia scenario). Hospital admission can trigger distress, confusion and delirium for someone with dementia that can contribute to a decline in functioning and a reduced ability to return home to independent living (Hospital Care, NICE), with poorer outcomes for DSD.

The hospital environment can be frightening and bewildering for people with cognitive disorders and is made worse by unfamiliar surroundings, continual noise and busy spaces. This can be in additional to the person experiencing perceptual and visuospatial problems associated with dementia, and these difficulties can trigger BPSD including agitation, disorientation and distress (which staff then require the skills to respond to).

In addition to this people with dementia in hospital experience loneliness, boredom, frustration, and fear, and consideration is not always given to their care partner who can support in conjunction with the hospital teams. People are often not able to access meaningful activity or engagement, which impacts their wellbeing, and can often result in behaviours of distress. This again relies on the ability of ward staff to have the skills to deliver meaningful activity for people with dementia.

Voices from stakeholders

Not enough is done in hospital to mobilise the person and prevent deconditioning."

Wards must know how to manage the basics - hydration, nutrition, making contact with people and getting people out fast."

Having meaningful activity on a ward doesn’t need to be complicated, but it does require thinking differently, e.g. dancing to a familiar song in bed, made all of the patients, their visitors and the ward staff feel and act more positively, all in the space of a few minutes."

Outcomes

E.1 Provide dementia attuned hospital care

• This will require thinking through the acute frailty pathway and developing a process map that begins with initial presentation at ED. 
• Once a process has been determined that will minimise moves, this will need to be embedded within the culture of the organisation, including the ability to audit ward moves and reflect on variation.

Staff need to:

• have the skills to care for the person with dementia, and be able to support them in management of delirium (including prevention, screening and treatment). This includes training in techniques such as re-assurance, distraction, activities that can manage behaviour in order to ensure the need for security guard intervention or medication are last resorts
• proactively prevent deterioration and respond to behaviours of distress by regularly reviewing hydration; maximising access to food; providing support to stay mobile and monitoring/ screening for other physical health signs, including pain and the development of delirium
• be part of a multidisciplinary team, with specialist oversight (e.g. specialist frailty practitioner) and access to further specialist input (e.g. mental health support/ liaison)
• use a strengths-based approach, including ward based reablement, interventions to optimise mobility, minimise deconditioning and loss of cognition
• welcome the care partner, recognising the unequivocal support they provide in achieving patient outcomes, reassuring the patient and reducing distressed behaviours. Review the ability for care partners to stay on the ward outside of normal visiting hours in line with John’s Campaign
• be able to communicate effectively with the person, their care partners, and teams across the hospital that are involved in the care of the person
• be able to facilitate and participate in conversations regarding discharge planning from admission onward, with a focus on getting the person home when it is safe and appropriate to do so.

• Use a strengths-based approach, including ward based reablement, interventions to optimise mobility, minimise deconditioning and loss of cognition. 
• Consider use of an activity coordinator function as part of staff members roles, supplemented by volunteers to undertake an activity calendar on the ward, to support cognitive and physical activity for the person. 
• Engage patients in meaningful activity, encouraged through provision of books, games, crafts, snacks, handrails, places to walk, including some where relatives and visitors are encouraged to participate alongside them. Activities should consider the paradigm the person is in and based on their likes/ dislikes to ensure that it is meaningful for them. 
• Reduce the consumption of caffeinated drinks in the evening, to promote a better quality of sleep.

E.2 Provide dementia attuned hospital environments

Using the Dementia Friendly Hospitals Charter requirements for the environment as a baseline, wards should aim to ensure: 

• people are not left on trolleys in the Emergency Department alone, recognising the detrimental effect this can have
• noise and distractions are minimised
• suitable/ appropriate Signage and orientation cues support navigation and ease decision-making throughout the building, helped by accent colours, artworks, large face clocks, natural light, outside spaces, clear signage, and visible staff
• familiarity is enabled through, for example, personal and self-care items, photographs and memory boxes
• where possible there are clear sight lines, even lighting and even coloured matt flooring, uncluttered spaces. 

Supporting resources 

• Dementia-Friendly Hospital Charter (NDAA) : For clear advice on the requirements for hospital based care and environment. 
• Improving hospital care for people with dementia (Healthcare Improvement Scotland) 
• Designing dementia-friendly hospital environments (Future Healthcare Journal) 
• The impact of a hospital-based special care unit on behavioural and psychological symptoms in older people living with dementia (Age and Ageing)