Analysis

How one organisation has enhanced acute care for older patients

Positive results shine through for trust's pilot scheme enhancing the care of older patients.

Positive results shine through for trust's pilot scheme enhancing the care of older patients.

Doncaster and Bassetlaw Hospitals NHS Foundation Trust has piloted a scheme enhancing the care of frail and vulnerable older patients, and staff are already seeing positive results.

Enhancing care team
 
Bassetlaw Hospital’s Enhanced Care Team
(back I-r): Sinu Jacob, Esther Lockwood,
Mandy Tyrrell and Melissa Wagstaff
(front I-r): Janet Ashton and Sheeba Joy
 

The trust, which has experienced an increased number of frail and vulnerable people admitted over the past five years, works on the philosophy that enhanced care helps to ensure patient safety while providing interventions to minimise the distress caused by being in a hospital environment.

Earlier this year an enhanced care team of four whole-time equivalent healthcare assistants (HCAs) with specific training in de-escalation (see panel), dementia care and falls prevention was set up as a six-month pilot project.

The team, who report to an advanced nurse practitioner in care of the older person, were placed at the Bassetlaw Hospital in Worksop to provide specialist, one-to-one care for patients with confusion, delirium or dementia.

The trust's frailty care group head of nursing, Cindy Storer revealed that around £8,000 a month was previously spent on bank and agency nurses to provide supervision of frail and vulnerable patients: ‘The nurses were in place to stop the patients coming to harm, but the concept of the enhanced care team is far more specialised and the patients have someone specifically trained to look after and spend time with them.

1.3 million

Hospital admissions in England in 2015-16 were people aged 65-69; the total number of admissions was 16.2 million

Source: NHS Digital

‘We’re not only saving money but we’re providing a specialist service.’

The NHS Confederation and the Alzheimer’s Society have found that people with dementia occupy about one quarter of beds in acute hospitals. In addition, a British Medical Association report published in September warned that the UK’s fragmented health and social care system is failing older patients as it is unable to cope with increasing pressure from an ageing population with more complex needs.

Ms Storer says that a falls prevention practitioner at the trust looked at examples of best practice for frail and vulnerable patients at Burton Hospitals NHS Foundation Trust and East Lancashire Hospitals NHS Trust, and the trust decided to put together its own enhanced care team.

‘We saw that there were HCAs who could be trained in falls prevention and making sure patients were up and out of bed safely and drinking more.

850,000

People in the UK who have dementia

Source: Alzheimer’s Society

‘When we piloted the team at the trust we realised change was needed in the organisational culture. Some of these patients will have complex care needs due to their other underlying conditions such as confusion, delirium or dementia, increasing the risk of them falling while in hospital. Yes, these patients are vulnerable and need extra care, but leaving them in bed is the worst thing to do.’

The trust is also making sure that every staff member is aware of the complex needs of frail older patients with a series of training and education sessions throughout the year.

In June, the trust held an event called Frailty Week where staff were invited to learn more about the treatment and care of older patients, equipping them with the skills and knowledge to treat patients in a more holistic way, helping them to recover and return to independence.

Another Frailty Week for staff was held in September with a focus on person-centred care, dementia and falls prevention.

4.6

Average number of additional chronic illnesses people with dementia have

Source: British Medical Association

Ms Storer says the trust has put together a series of quality measures to assess the effect of the enhanced care team and is already seeing a difference in most areas, including reduced falls and more supervised toileting.

Care duties

The HCAs undertake care duties including washing, dressing, nutrition and toileting along with patient observations, documenting and reporting them to an appropriate member of staff.

The team liaises with relatives, carers and other health professionals. They are expected to complete This is Me, a booklet devised by the Alzheimer’s Society, to assist them in conversation and choice of activities with the person they are caring for.

Ms Storer says feedback from staff and families has been positive: ‘We did a pilot study of staff to see the effect of the education sessions and the enhanced care team. We wanted to know if staff felt safer when around patients with delirium or dementia as they can sometimes come across as being aggressive.

‘Out of 50 members of staff, 49 said they found the trust was a safer place to work.’

Ms Storer says she is helping to put together a business case to implement the enhanced care team at two other sites at the trust.

‘The holistic care we are putting in place for older people has been a team effort and we are looking forward to seeing all the benefits.’

Therapeutic activities

Each shift for the enhanced care team needs to include an activity from each of these five areas, which must be documented on a supervision chart. Examples include:

Cognitive activity

  • Read a newspaper.
  • Complete a crossword/quiz.
  • Complete a jigsaw.
  • Read a book together.

Physical activity

  • Walk around the ward.
  • Move from bed to chair.
  • Move arms and legs in bed.
  • Reach for items on the table.
  • Throw/catch with a soft ball.

Social

  • Talk about current affairs.
  • Talk about families.
  • Talk about television programmes.
  • Sit at a table with other patients.
  • Have a cup of tea together.

Personal hygiene

  • Encourage to shower, assist where necessary.
  • Brush teeth in the morning and before bed.
  • Wash hands before meals.
  • Brush hair.
  • Assist with shaving.
  • Change clothes and bedding.

Calming

  • Hand massage.
  • Listen to music.
  • Have a story read to the patient.
De-escalation techniques

The enhanced care team use the following de-escalation approaches:

Voice

  • Gentle and calm tone.
  • Familiar words.
  • Use person’s name regularly.
  • One question at a time.
  • Ensure understanding.
  • Be positive.

Body language

  • Open posture.
  • Calm demeanour.
  • Smile.
  • Appropriate eye contact.
  • Go slow and give plenty of space.

Distraction

Validation

  • 'That sounds very worrying to you.'
  • 'I can see you are very upset about this.'
  • 'I’m sorry that you are feeling this way.'
  • 'Is there anything you would like me to do to help?'

Activity

  • Fold sheets
  • 'Can you come and help me with this first?'
  • Move (empty) boxes
  • File
  • Make the bed
  • Word quizzes
  • Cup of tea
  • Prepare some food
  • Colouring

 Moving along

For example: if a patient starts asking to go home, start talking to them about home:

  • Where do you live?
  • What shops are nearby?
  • Did you work nearby?

Environment

  • Move rooms.
  • Go for a walk.
  • Pull curtains around the bed area.
  • Remove obstructions.
  • Increase/decrease light as required.
  • Give plenty of space.

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