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P3. Hospital care

Detailed programme and abstracts

P3. Hospital care (Tuesday 1 Nov., 14.00 - 15.30)

P3.1. The worthy patient in rehabilitation hospitals

DIGBY Robin, WILLIAMS Allison, LEE Susan

The number of people with dementia admitted to hospitals is increasing worldwide often with poor patient outcomes. It is important to examine the nurses' perspective to identify opportunities for improving care. This paper presents the findings of a qualitative study exploring the experiences of nurses caring for people with dementia in five wards of two Melbourne Australia metropolitan rehabilitation hospitals in 2014.

Ethnographic conversational interviews were conducted with 30 registered or enrolled nurses aged between 25 and 68 years with median nursing experience of 20.3 years.  Participation was voluntary and formal consent was obtained before interview. Participants spoke about their experiences caring for people with dementia in hospital, and the factors which contributed to their ability to care effectively. The interviews were digitally recorded, and transcribed verbatim prior to thematic analysis.

Nurses reported that the governance of fiscal restraint influenced hospital culture, focusing on acute care and minimising patient length of stay. Risk mitigation and protection were prioritised ahead of caring practices and empathy. Patients with dementia were considered less worthy of resources than patients with acute health issues and sometimes referred to as 'bed-blockers'.  Some participants said that patients should be cared for in 'dementia-specific' facilities.

Nurses can find working in geriatric rehabilitation stressful and frustrating however there is little psychological or practical support provided. Education about dementia is scant. Nurses reported being too busy to provide more than basic care. Extra staff are rarely granted to assist with patients with behavioural symptoms. 

The new governance of fiscal restraint effects hospital culture and encourages nurses to consider patients with dementia as less worthy of care than those with acute illnesses.  Narratives which stigmatise or refer to a patient's unworthiness must be discouraged. Nurses require adequate psychological, educational and practical support to provide appropriate care for their patients.

P3.2. DemPath-the creation of an integrated care pathway (ICP) for people with dementia in a university teaching hospital in Dublin, Ireland

COLE Natalie, MCMAHON Geraldine, Mc CARROLL Kevin, LAWLOR Brian

The Irish National Audit of Dementia Care in Acute Hospitals 2013 reported that there are no dementia pathways in place, little dementia training and awareness programs and poor design features for people with dementia. This is a major issue for general hospitals from a fiscal and clinical point of view.

St James's Hospital, Dublin , a large university teaching hospital with over 1000 beds undertook a three year project to improve the experiences of people with dementia within the hospital setting.

As part of the creation of an ICP for people with dementia DemPath completed process mapping of the “as-is “process for the person with dementia in St. James’s Hospital and we found that there is no standardised assessment  in ED for cognition/dementia/delirium, only ad hoc assessment for dementia throughout the hospital, no routine use of cognitive assessments, no screening or prevention for delirium, discharge letter provides little or no information on dementia, duplication of information collected by multiple people and multiple referrals for 2nd opinion

With extensive stakeholder engagement DemPath has created the “to-be “design of the ICP which includes flagging of individuals over 65 with dementia/cognitive impairment/delirium at presentation to the Emergency Department using the 4AT test, follow-up assessment of cognition and delirium during admission and documentation of same assessments on discharge. The project is at implementation phase of the “to-be “design and the data generated provides the hospital with information for workforce planning and for implementing best practice for the individual during their hospital stay.

This paper will discuss findings, challenges and progress to date in the creation of an ICP for people with dementia in an acute care setting

P3.3. Caring for people with dementia in community hospitals: An ethnomethodological study of everyday decision-making 

BROWNBILL Paul, KENKRE Joyce, LLOYD-JONES Nikki, HIGGINSON Ray, PAGE Sean

Rationale: In the UK, Community hospitals have historically been accessed as a bridge between acute services and home. However, their role has changed resulting in staff facing significant challenges about how to manage increasing numbers of people with dementia and who are staying longer. Concerns about NHS care (Francis, 2013), and need for improved service provision (Alzheimer’s Society, 2011) prompted research about these particular hospitals as a care context. 

Aim: This study explores resources and influences on every-day decision-making of those with experience of people living with dementia who are admitted to community hospitals. The focus is to make explicit, social and professional paradigms of influence through everyday activity and language.

Methods: Accounts were gathered through 4 weeks of observations of practice at 3 community hospitals. Additionally, 3 group interviews were undertaken with relevant participants, including carers, and community hospital staff. Furthermore, artefacts participants used during decision-making were gathered.

Methodology: Using Garfinkel’s (1967) ethnomethodological approach, the study discusses how social interaction produces and preserves everyday taken-for-granted reality and how actions and activities are seen as essential for preserving social order.  Ethnomethodology suggests that everyday activities, including language are accountable to others. Accountability is the way that the social world is describable, reportable and analysable by those within a context/paradigm.

Discussion: The presentation will centre on findings from the observations with regards to how the context of care for people with dementia in community hospitals is produced, and how this can have an impact on practice. Additionally, the presentation will focus on the processes and resources people use during decision-making for and with people living with dementia. Furthermore, preliminary findings will inform a conversation about a tentative model of decision-making which will be enhanced with data from a second phase of observations in this longitudinal research, (Coulon, 1995).

P3.4. Dementia in acute care hospitals in Switzerland

GADIENT Nicole, scientific collaborator of the Swiss Alzheimer’s Association

The Swiss Alzheimer’s Association conducted an initial survey on the current situation of patients with dementia hospitalised on surgical wards and internal medicine (and their outpatient clinics). We focused on these two units because patients with dementia often enter in these wards for other reasons such as hip fractures caused by falls.

An online survey was sent to physicians from the 188 acute care hospitals in Switzerland including questions like the following:

What’s the estimated prevalence of dementia on the surgical ward and the internal medicine? What are the differences between patients with and without dementia? What about specific measures and offers for people with dementia? What’s the main role of the caregivers?

In a complementary survey a parallel questionnaire was sent to family caregivers. The comparison between the two perspectives gave the unique possibility to identify discrepancies and the deduction of concrete recommendations for optimisation. Results of the complementary analysis will be presented.

Main conclusions

  • Better knowledge about dementia is elementary in order to guarantee good quality care.
  • Family caregivers need to be more involved as they are the most important source of information concerning the patient with dementia.
  • Dementia-appropriate pathways especially for admission to and discharge from hospital should be developed in order to prevent expensive re-admissions.

Finally, the results have an impact on the political level as input to the National Dementia Strategy in the implementation project “Promotion of dementia-appropriate care in acute care hospitals”.

P3.5. Partners in care – Involving and supporting carers in the hospital setting

SKINNER Helen

Scotland’s 2nd National Dementia Strategy (2013-2016) outlines various commitments to improving the care of people with dementia, and their carers. A specific commitment focuses on the care of people with dementia in the hospital setting, detailing 10 Dementia Care Actions for improving care. Care Action 8 prioritizes working as equal partners with families, friends and carers. This presentation will describe two innovative approaches that are being used in a busy acute care hospital to involve and support carers in the care of their loved one, working in partnership with healthcare staff.

Partners in Care – this is a model of care that actively invites carers to participate in the care of their loved one whilst in hospital. It recognizes that the needs of a person with dementia may be best met by those who know them best, so the voluntary involvement of carers is encouraged and supported. Involvement may include assisting with mealtimes, personal hygiene, or however the carer would like to be involved. This promotes a personalized approach to care which is informed and driven by carers.

Dementia Carers’ Café – it can be a stressful and worrying time when a loved one is admitted to hospital. The Dementia Carers’ Café was developed as a result of recognizing this, and is a measure to support carers of people with dementia whilst in hospital. It takes place in the acute hospital setting and is held prior to visiting time, giving opportunity for carers to attend before visiting their loved one. The café is run by the Dementia Nurse Consultant and is a relaxed informal event where carers can talk, share their concerns and worries, ask questions, and receive advice, help and support.

This presentation will emphasize the key role of working in equal partnership with carers in delivering person centred, safe and effective care to people with dementia when in hospital. Through involving and supporting carers an open and inclusive culture is promoted, resulting in positive outcomes for people with dementia.

P3.6. Using qualitative evidence synthesis to explore caring for people with dementia in acute setting

CASEY Dympna, HOUGHTON Catherine, MURPHY Kathy, BROOKER Dawn

Qualitative evidence synthesis can inform practice and policy development by bringing together the findings of qualitative research in a comprehensive, systematic and meaningful way. It is well known that acute settings are often not an appropriate environment for people with dementia. This environment can worsen symptoms of disorientation and distress and therefore may delay or prevent discharge home. The aim of this qualitative synthesis was to explore health care staffs’ experiences and perceptions of caring for people with dementia in acute care.

A systematic search strategy and screening process resulted in 12 reports of nine qualitative studies exploring this topic. Framework synthesis was conducted to synthesise the findings of the studies. The framework was developed using Dawn Brooker’s VIPS framework incorporating: Values, Individualised care, Perspective of the person with dementia, and Social and psychological.  Critical appraisal of the quality of the studies was conducted using the Critical Appraisal Skills Programme (CASP) tool.

The synthesis identified barriers to appropriate care for the person with dementia in the acute setting. These included ineffective pathways of care, unsuitable environments, inadequate resources and staffing levels and lack of emphasis on education and training for staff caring for people with dementia. Recommendations are made for practice consideration, policy development and future research. Through qualitative evidence synthesis, it was possible to draw conclusions from a number of studies and this strengthens the findings and recommendations, which, in turn, provides better evidence for policy makers.  The VIPS framework was considered invaluable to this review and it is recommended that it be used to guide decision making for how best to care for people with dementia in the acute setting.

 

 
 

Last Updated: Tuesday 10 January 2017

 

 
  • Acknowledgements

    The 26th AE Conference in Copenhagen received funding under an operating grant from the European Union’s Health Programme (2014-2020). Alzheimer Europe and Alzheimerforeningen gratefully acknowledge the support of all conference sponsors.
  • European Union
  • Roche
 
 

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