Making the right moves
Liaison psychiatry team lead Nicola Wood has significantly improved the hospital experience for patients with dementia and their carers by slashing the number of moves they experience.
A nurse has significantly improved the hospital experience for patients with dementia and their carers by slashing the number of moves they experience, and by ensuring clinically necessary moves are made earlier in the day.
Liaison psychiatry team lead Nicola Wood’s collaborative approach is enabling nurses to reduce the risk of delirium and distress.
Ms Wood, who works at Forth Valley Royal Hospital in Larbert, Scotland, says: ‘Delirium is associated with poor outcomes, including increased length of stay, long-term reduction in functional ability and increased mortality.
‘Multiple and late moves can also increase the risk of stress and distress symptoms, such as agitation, emotional changes and aggression, among people with dementia.’
people in 500-bed hospital Forth Valley Royal have dementia at any one time
Ms Wood became concerned that older people with dementia were being moved unnecessarily and, on investigating, found half of all moves took place after 8pm, with 10% after midnight. One third of patients were experiencing two or more moves. One person had experienced seven moves in five days.
‘Once I had seen what was happening, I could not ignore it,’ says Ms Wood. ‘But I was a bit naïve. I thought I could simply ask people to stop moving patients and the job would be done. I soon realised it would be a massive job requiring a whole-systems approach.
‘This was daunting because each specialist area has different priorities and pressures, and different ways of working.’
A root-cause analysis showed that patients with dementia were not being highlighted for the patient flow team when they were admitted. The liaison psychiatry team began providing the patient flow team with a daily list and highlighted the names of patients with dementia on the multidisciplinary team board.
The patient flow team began keeping a log of patients who had been moved late in the day. ‘We looked at the common themes and shared learning, and any moves after midnight were reported and fully investigated,’ says Ms Wood.
Freeing beds earlier in the day in downstream wards was crucial, as was improving the discharge lounge.
‘I liaised with local health authority managers and social work departments to see if there was any way we could start discharge packages of care earlier in the day,’ Ms Wood says.
‘We had got into the habit of starting it in the evening, but I knew that if we could discharge earlier, we could free up a bed for an early transfer.’
For the first two months of her project Ms Wood worked hard to get people on board. She explains: ‘Staff had reported feeling frustrated about patient flow. It was a matter of getting to know the different staff members and explaining the benefits to them, one by one.
people with dementia are moved before 8pm, up from 52% a year earlier
‘I also had the senior manager on board so I did a lot of name dropping. By months three and four, we had good results. People were pleased with what they could achieve and more people came on board.’
Tailored education and awareness sessions for staff had a significant effect on the project’s results, which are impressive. Year on year, the number of people moved before 8pm has risen from 52% to 92%, while those requiring two or more moves has fallen from 33% to 2%. The number of patients moved after midnight has been reduced dramatically.
Meanwhile, staff report they are more confident in advocating for patients.
NHS Forth Valley director of nursing Angela Wallace says she is ‘truly impressed’ with Ms Wood’s commitment and dedication.
‘Her work to improve care, compassion and safety is recognised as a trailblazer,’ she says. ‘Treating dementia well has to be everyone’s business, and Nicola is a shining example of someone setting a high bar for standards of care.’
Ms Wood was highly commended in the Nursing Older People category of the prestigious RCNi Nurse Awards 2017.
Chair of the RCNi editorial advisory board and judge Caroline Shuldham says: ‘Nicola recognised the detrimental impact that being moved frequently and late in the day has on people with dementia.
‘She could have argued it is not part of her role to resolve this problem, but instead worked with colleagues across departments and specialties to improve continuity during patients’ stays. Her work has benefited patients and empowered nurses.’
Maintaining improvements is not easy, says Ms Wood, but it proved sustainable over winter. To raise awareness, she sends a monthly report of the moves experienced by patients with dementia.
of patients have had two or more moves, down from 33% a year earlier
‘If there has been a dip, senior managers and consultants try to motivate their teams. But generally, the dips correspond with how busy the hospital is.
‘If it is 9pm and the alternative is leaving them to try to sleep in the emergency department, we move patients. But when we have investigated late moves we have found they were undertaken for the right reason – clinical indication.
‘And we don’t have anyone who has experienced more than two moves.’
Because of its success, the project has been extended to include patients with delirium.
‘All this has been accomplished by professionals from diverse backgrounds working in various roles and specialties, whose paths may never have crossed before, coming together to achieve a common goal: significantly improving the experiences of people with dementia and their families or carers after hospital admission,’ says Ms Wood. ‘And I am most proud of that.’
‘Carer feedback is a powerful motivator’
One of the most important factors in the initiative’s success has been carer and patient involvement.
‘My advice to anyone considering starting a similar project would be to include patients and their carer where you can,’ says project lead Nicola Wood.
‘Not only was their feedback important for shaping our improvements, it has been a powerful motivator.’
Ms Wood has developed links with the local carer’s centre in Falkirk and now makes twice-yearly visits.
When Ms Wood first visited, the concerns raised by carers drove her to improve the hospital journey for patients with dementia and to minimise the number of patient moves.
‘They highlighted this as an area in which they were unhappy with their experience,’ she says.
Ms Wood built on the initial visit to explain what the hospital was trying to do to improve the experience of patients with dementia or cognitive impairment.
‘I realised that we were getting good information about what was important to the carers and patients, and what they would like to see to improve their hospital admissions,’ she says.
‘So I asked them if I could come back because the information was useful.’
On her last visit in February, Ms Wood had a different experience from 18 months previously. The carers had no negative feedback and several reported that, when patients were transferred to different parts of the hospital, their carers could accompany them.
One man said: ‘An afternoon transfer meant that I was able to help my wife re-adjust to her new ward. I could walk her around the ward, show her where everything was, help get her photos and other things out just where she likes them. I could also tell my son exactly where to go to when he visited.’
Ms Wood says it is reassuring to hear that carers are feeling the difference.
‘It has been great to share those experiences with the extended team,’ she adds. ‘It shows that this is not all about data and charts, but about people’s lives and their experiences when they are vulnerable.’
Nursing Older People would like to thank Bupa for sponsoring the Nursing Older People award at the RCNi Nurse Awards 2017