Dementia and delirium: making late-night patient transfers a thing of the past

A nurse-led project to avoid moving patients at night has helped reduce the risk of anxiety and distress, and improved relationships with carers

A nurse-led project to avoid moving patients at night has helped reduce the risk of anxiety and distress, and improved relationships with carers

Nicola Wood (centre) with colleagues at Forth Valley Hospital in Larbert.
Picture: Mike Wilkinson

Moving patients around a hospital, especially at night, can have a detrimental effect on their health. But a nurse consultant in Scotland is significantly improving the hospital experience for patients and carers by reducing the number of moves and ensuring that when they are clinically necessary they take place earlier in the day.

Nicola Wood’s collaborative approach to improving the inpatient journey for people with dementia has been so successful that she is extending the programme to include all patients with a diagnosis of delirium admitted to the Forth Valley Royal Hospital, Larbert.

‘Delirium is associated with poor outcomes, including increased length of stay, long-term reduction in functional ability and mortality,’ says Ms Wood, Alzheimer Scotland dementia nurse consultant at NHS Forth Valley. 

Risk of distress

In 2015, Ms Wood became concerned that older people with dementia were being moved around the hospital unnecessarily. On investigating, she found half of all moves took place after 8pm, with 10% after midnight. A third of patients were experiencing two or more moves during their stay, with one person moved seven times in five days.

‘Multiple and late moves can increase the risk of stress and distress symptoms for those with dementia, including agitation, emotional changes and aggression,’ she says.

Picture: Mike Wilkinson

‘I couldn’t ignore it, but I naïvely thought I would just ask people to stop moving patients and job done. I soon realised it required a whole systems approach.’

Everyone on board

After a root cause analysis showed that patients with dementia were not being brought to the attention of the patient flow team, Ms Wood’s team began providing them with a daily list and highlighting these patients on the multidisciplinary team board.

The patient flow team began keeping a log of those moved late at night. ‘We looked at the common themes and shared learning,’ says Ms Wood. ‘Any moves after midnight were reported and fully investigated.’

Freeing beds earlier in the day in other wards was crucial, as was improving the discharge lounge for patients. Ms Wood also worked hard to get people on board, ‘one by one if I needed to,’ she says.

Awareness sessions

More staff were persuaded by the positive results – the percentage of people with dementia transferred before 8pm rose from 52% in November 2015 to 97% in July 2017, while the percentage experiencing two or more transfers fell from 33% to zero in the same time frame.

‘I naïvely thought I would just ask people to stop moving patients and job done. I soon realised it required a whole systems approach’

Nicola Wood

Tailored education and awareness sessions for staff had a significant effect on the project’s impressive and sustained results, for which Ms Wood was highly commended in the Nursing Older People category of the RCNi Nurse Awards 2017.

‘We had a dip in December 2017 and the following month, but we had a high number of confirmed flu cases so there was a lot of movement to ensure those requiring isolation were cared for in the right place,’ says Ms Wood. ‘But people were moving for the right reason. The transfer had been thought through and the documentation was robust.

Tracking their journey

‘In the six-month period before that we had no transfers after midnight,’ she adds. ‘Staff were really disappointed when we had one recently, but it kept their motivation up, and the data I have had from February is excellent.’

Nicola Wood: include patients and carers in discussions where possible.
Picture: Mike Wilkinson

Expanding the work to patients admitted with delirium has been challenging because accurately tracking their hospital journey retrospectively, using their notes, can be difficult.

‘Presentation can change very quickly with delirium,’ says Ms Wood. ‘Someone could be admitted with a positive diagnosis, but three days later, when they are flagged up as being moved, they might have improved and it is appropriate for them to be transferred.

‘So although the results are not as clear, the patient journeys are reducing. We have done a lot of education with our staff and we trust them to put this into effect.’

Unexpected result

The clear benefits of the scheme for patients with dementia has given Ms Wood credibility, and the relationships built up in the project’s first phase have also been key to its success.

Examining the journeys of patients with delirium also revealed an unexpected consequence – it highlighted how many people with the condition were dying in hospital.

‘Research tells us that one in five patients with delirium will die, but to actually have hard evidence of it in our area is a real eye-opener. Now I have this information, I am working to see how we can reduce it,’ says Ms Wood.

‘It has also been powerful to share this information with staff, which will hopefully drive continued improvement.’

Nicola Wood: education and awareness sessions helped create staff support
for the project. Picture: Mike Wilkinson

Powerful motivator

Nurses interested in improving the patient experience by reducing unnecessary in-hospital transfers should include patients and carers where possible, says Ms Wood.

‘Feedback from carer groups is a powerful motivator for all involved,’ she says. ‘It shows that this is about people’s experiences at a time of heightened anxiety, and allows everyone to see the person rather than the patient.

‘There were a lot of complaints when I first visited the nearby carers’ centre, but it couldn’t be more different now. They feel like partners in their loved one’s care, and know exactly where they are going. Our relationship with them has blossomed.’

Elaine Cole is managing editor, Nursing Standard 


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