Dementia care: improvements needed

• Apr 12, 2012

The National Audit of Dementia was commissioned by the Healthcare Quality Improvement Partnership (HQIP) and carried out by the Royal College of Psychiatrists’ Centre for Quality Improvement in partnership with other organisations. The main audit looked at data collected from 210 hospitals across England and Wales. Ward level data was collected from a sample of 145 wards across 55 hospitals. This included 2,211 staff questionnaires, and 105 observations of care on the ward, carried out by hospital staff. It brings together key recommendations from five major policy documents1-5 and demonstrates that these broadly align, and identifies that there is a ‘road map’ for the components of quality care. The audit identified that, although the majority of wards do meet basic safety requirements, many had not addressed simple measures that could lessen the distress caused to dementia patients by an unfamiliar and confusing hospital environment. The report also found that staff training was lacking, with less than one-third of staff surveyed believing that their training and development in dementia care was sufficient. Observations of care carried out for the audit found that care is often delivered in an impersonal manner, by staff who did not fully understand the needs of patients. Considering that there are around 750,000 people with dementia in the UK, with this figure forecast to increase to over a million by 2021, this is an issue that must be addressed. Although hospital care can offer little in the way of treatment for dementia, patients with dementia often have additional health or behavioural problems that increase their risk of requiring admission to hospital. For example, they often become more confused and distressed. They are at risk of falling, acquiring an infection or becoming institutionalised and less able to care for themselves at home. The main reasons for admission to hospital for people with dementia are because of a fall (14%) or fracture (12%), urinary tract infection (9%), chest infection (7%) and transient ischaemic attacks (7%).6

The cost of care

There is evidence to show that the cost of care in the acute environment is greater for patients with dementia. A National Audit Office report7 found that for people with dementia the average duration of stay in hospital after a hip fracture was 43 days, compared with 26 days in patients who are psychiatrically well. In its ‘Counting the cost’ report (2009),6 the Alzheimer’s Society DEMHOS study data shows that 25% to 35% of patients with dementia admitted with these problems remained in hospital for over one month. Evidence collected for the report demonstrates a lack of leadership both at Trust/Health Board level and at hospital level, in terms of identifying champions and leads and identifying required resources. The report authors suggest that Trust Boards/Health Boards require better intelligence and information relating to the admissions, care, treating and discharge of people with dementia to enable the necessary improvements to processes and overall governance to be made to consistently deliver a good standard of care throughout the hospital.

Assessment failings

People with dementia who are admitted to hospital should have their physical and mental health needs assessed in addition to assessment relating to their ongoing care, to ensure the best recovery outcomes and safer discharge. Hospital guidelines or procedures often set out the range of assessments that should be expected. The results of the case note audit showed that important elements of assessment were not being routinely carried out. For example, only 70% of case notes showed that an assessment of nutritional status had been carried out and only 43% showed that a standardised mental status test had been carried out. Further, 13% of case notes showed no formal pressure sore risk assessment; 19% did not show that the patient was asked about any continence needs as part of the assessment; and 24% did not show that the patient was asked about the presence of any pain as part of the assessment. These findings demonstrate that there is currently a wide gap between policy and practice and the report authors believe that adherence to multidisciplinary assessment procedures need to be clarified and reinforced. Key findings from the report include:

• Only 6% of hospitals had a care pathway in place for people with dementia – although 44% did have one in development at the time of the audit.
 • Only 32% of staff said that their training and development in dementia care was sufficient.
• 50% of staff felt they had not received sufficient training in communication skills specific to people with dementia, and 54% felt they had not received sufficient training in dealing with challenging or aggressive behaviour.
 • Very few wards demonstrated a culture which was ‘person-centred’, where the person with dementia is treated as an individual and their perspective taken into account in a supportive environment.
• 59% of wards reported that personal items were not situated where the patient could see them for reassurance.
• Only 15% of wards used colour schemes to help patients with dementia find their way around the ward, while only 38% of wards said that signs in the ward were large, bold and distinctive.

 The report goes on to make a series of recommendations to help address the issues raised, including:

• All staff should be provided with basic training in dementia awareness, and a specified proportion of ward staff should receive higher-level training.
• Assessment of staffing levels must take account of the additional support needs of people with dementia.
• A senior clinical lead for dementia should be in place in each hospital with designated time in their job role to develop, implement and review the dementia pathway. These clinicians should identify dementia champions in each department in the hospital and at ward level.
• Ward managers should make sure that staff can involve people with dementia and their carers in discussions on care, treatment and discharge.
• Systems for guidance, supervision and support should be in place for staff caring for people with dementia. Health departments in England and Wales should provide guidance on dementia-friendly ward design. These should be incorporated as standard into all refurbishments and new-builds.
• Simple and effective improvements to the environment should be carried out in all wards admitting older people, including orientation aids such as colour schemes and personalising bed areas.

Work has begun

On a positive note, some hospitals have already begun work locally to address the issues raised in the report, after receiving local reports from the audit team early in 2011. Many have now submitted action plans detailing key actions for improvement which include awareness training for staff (59 hospitals); identifying dementia champions (25 hospitals); development or review of the care pathway (36 hospitals); and improving involvement of carers (18 hospitals). Commenting on the report Professor Peter Crome, chair of the National Audit of Dementia Steering Group, said: “We have provided a number of recommendations that, if implemented, will enable patients and their families to have confidence in their hospital treatment. It is good to see that several hospitals have responded to the results of the interim findings with programmes of quality improvement. Hopefully real change will be seen in the results of the next national audit, which is due to be published in June 2013.” Dr Kevin Stewart, clinical director of the Royal College of Physicians’ Clinical Effectiveness and Evaluation Unit, believes that there is much work to be done to make sure that patients with dementia get the best possible care in hospital. He said: “They deserve no less, and we are delighted that the NHS in England has made the care of this group one of its top priorities. The Royal College of Physicians will work with clinicians, health service managers, the Department of Health and the wider NHS to ensure that we bring standards across the country up to the best achievable.” The Royal College of Nursing (RCN) expressed concern over the fact that many staff say that their training and development in the field of dementia care is not sufficient. Dr Peter Carter, Royal College of Nursing chief executive & general secretary, commented that it is essential that all staff are supported through training, education and leadership so that they able to provide skilled, knowledgeable care to people with dementia. He called for nurses, who are personally accountable for their own practice, to act promptly to raise concerns if they believe that staffing levels, or other pressures, are getting in the way of delivering good care. :

References

1 National Institute for Health and Clinical Excellence and Social Care Institute for Excellence (2006). Dementia: Supporting people with dementia and their carers in health and social care. 2 Alzheimer’s Society (2007). Dementia UK: The full report. The Personal Social Services Research Unit (PSSRU) at the London School of Economics and the Institute of Psychiatry at King’s College London. 3 Department of Health (2009). Living well with dementia: A National Dementia Strategy. 4 National Institute for Health and Clinical Excellence (2010). Dementia quality standards. www.nice.org.uk/aboutnice/ qualitystandards/dementia/ dementiaqualitystandard.jsp 5 Skills for Care, Skills for Health (2011). Common core principles for supporting people with dementia. 6 Alzheimer’s Society. Counting the Cost (2009). 7 Henderson C, Malley J, Knapp M. Maintaining good health for older people with dementia who experience fractured nack of femur; report for phase 2. (2007). Report for the National Audit Office.