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How to make a ward day room a place where patient outcomes are transformed

A nurse explains how she is achieving her vision of combatting deconditioning risk and supporting early discharge  
Occupational therapist Anna Tilney takes tea with a patient, who is dressed in his day clothes

A nurse explains how she is achieving her vision of combatting deconditioning risk and supporting early discharge

Winter presents many challenges to our patients and our acute hospital. As a senior sister and ward manager of a 26-bed mixed acute older people's ward that specialises in dementia care, I need to ensure safe, holistic care for my patients at the point of discharge. There is also a need to discharge patients earlier in the day to release the bed and support patient flow. The Dayroom to Doorstep project was the direct result of balancing these two demands.

The aim of the project was to use the day room as a resource a space to be used to reduce patients'

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A nurse explains how she is achieving her vision of combatting deconditioning risk and supporting early discharge

Occupational therapist Anna Tilney and patient Trevor Wade take tea together in the day room 
Picture:  Stephen Shepherd

Winter presents many challenges to our patients and our acute hospital. As a senior sister and ward manager of a 26-bed mixed acute older people's ward that specialises in dementia care, I need to ensure safe, holistic care for my patients at the point of discharge. There is also a need to discharge patients earlier in the day to release the bed and support patient flow. The Dayroom to Doorstep project was the direct result of balancing these two demands.

The aim of the project was to use the day room as a resource – a space to be used to reduce patients' risk of deconditioning, increase their physical activity levels and boost their mental well-being through participation in timetabled, structured activities and social interaction with staff and other patients. This would have the benefit of supporting early discharge: the day room would be a safe and familiar place from which patients could be discharged and for families to feel confident when collecting loved ones.

Re-engagement with activities of daily living 

The project began in March 2019 following a particularly challenging winter when the day room had been used as part of the trust’s escalation plan to accommodate one extra patient during times of extreme pressure.

I realised that by using the day room in a more SMART (see box) way, the ward would be able to provide holistic care that supported the #end PJ Paralysis campaign, reducing deconditioning in a number of patients. This in turn would support the safe discharge of a greater number of patients, who would have re-engaged with the activities of daily living through their use of the day room.

Physiotherapy assistant Bo Novak helps patient John Nichols get to grips with an audio book  
Picture:  Stephen Shepherd

What does SMART mean?

SMART stands for:

  • Specific Make a clear statement of what you are trying to achieve
  • Measurable Have a numerical target that can be measured
  • Achievable Ensure your goal is realistic and attainable in the time available 
  • Relevant Link the activity to the strategic aims of your organisation and relates to patient outcomes
  • Time-bound Have as a clear time frame 

Source: NHS Improvement

 


Watch: Most Innovative Team of the Year 2019 - Dayroom to Doorstep Project team


Alessandra Johnson walks with
patient Trevor Wade to the day room  
Picture:  Stephen Shepherd

Trust’s nursing director gave me courage to challenge established practice

Key to the project was a having a ward therapist who was based on the ward and straddled both nursing and occupational therapy roles. This was a new role to the ward – it could be filled by an occupational therapist or a physiotherapist. Without the engagement from the ward therapist and her team leader the project would have struggled to get up and running.

Stakeholder engagement throughout has been vital. However, from my perspective the most pivotal person was the director of nursing and midwifery. She gave me the courage to challenge the established practice in the day room, and the authority to launch a new initiative.  

Seasonal spike in bed pressures gave me the real-life case study evidence I needed

Fairly early on, we encountered a few challenges, particularly over Easter, when pressures increased and the day room was once again used as an escalation area to accommodate one additional patient. While frustrating, this provided us with additional evidence of the benefit of the ‘dayroom to doorstep’ approach: we were able to demonstrate that had we been able to use the day room for the project, we would have provided the trust with four early discharges on the Tuesday after the bank holiday.

The requirement to use the day room as an escalation area, and accept an additional patient, meant we were not able to mobilise any other patients and four beds became available to the trust much later in the day. This example gave the team real impetus to drive the project forward.

Visits from a PAT (Pets as Therapy) dog are a regular fixture of the day room timetable 
Picture:  Stephen Shepherd

Quality improvement team helped me develop a data collection tool

I realised early on that I would need to demonstrate whether the project was of benefit, so I engaged with members of our quality improvement team. With them, I developed a data collection tool, which they were able to take away and analyse, looking specifically at the numbers of patients using the day room and the numbers and types of activities, along with the time patients stayed in the day room.

They also collected patient experience data. Data relating to length of stay and time of day of discharge was already collected by the business intelligence unit. We have averaged more than 45% of discharges before noon in recent months. 

Data has been vital in proving the benefits of the project – however this has also thrown up its own challenge; understanding data anomalies has been essential when discussing the project.


A week's itinerary, posted up outside
the day room

Advertising activities on a whiteboard helped ensure they actually happened

A timetable of activities was developed that we advertised outside the day room for all patients, relatives and staff to see. This helped to formalise the activities and ensured they actually happened. The activities, led by the ward therapist and volunteers, include crafts, baking in our therapy kitchen, singing and lunch club and tea parties. We also run regular activities in the ward's garden. 

Relatives often tell us how special the day room feels – it is a homely place where they can spend time with loved ones. When it is time to be discharged the patient can wait in a safe and welcoming place while waiting for their transport home.  Indeed, a relative told me the other day that the ward itself also feels more homely since the Dayroom to Doorstop project began.  

Initially patients were identified each morning for the day room project if they were being discharged via the ‘home first’ route. However, as the project has developed we have extended the use of the day room to all patients who are not acutely unwell.

Freedom to remain in the day room enhances nutritional intake

Patients can stay in the day room for as long as they like, enjoying their meals and chatting to others. This has increased their fluid intake and the amount of food that they are eating as well has having a calming effect, particularly on our patients with dementia.

Being encouraged to get dressed in day clothes, to mobilise and socialise prepares our patients for their return to home life and has been instrumental in reducing their stay in hospital. Our overall length of stay on the ward has reduced from an average of 10.2 days in January 2019 to an average 6.1 days in January 2020 – though it should be noted that this project is just one of many initiatives that affect length of stay. 

Spending time in the day room – here Trevor Wade is listening to Frankie Simpkins on
the ukelele – can improve patients' nutritional intake  Picture:  Stephen Shepherd

Gaining the support of the multidisciplinary team

Initially, engaging with staff was challenging, because they felt the new approach was going to increase their workload. However, feedback ten months on suggests colleagues fully support the initiative, which is now embedded in the culture of the ward.

We pride ourselves on having a fully engaged multidisciplinary team. Our medical colleagues routinely identify patients suitable for the day room in their whiteboard rounds. The healthcare assistants work with the therapy assistants and ward therapist to mobilise patients to and from the day room as required. The nurses have changed their practice: the more well patients are now in the day room, which releases time for them to care for people who are more acutely unwell in the bays, with the knowledge that other patients are being supported, observed and monitored by trusted colleagues.   

Helen Slocombe, third from left, with multidisciplinary colleagues  
Picture:  Stephen Shepherd

Social media has brought our work to a wider audience with an interest in #end PJ Paralysis

Social media has brought this project to a wider audience, culminating in the summer of 2019 in our participation in the EndPJParalysis global summit led by Brian Dolan, the nurse who created the #end PJ Paralysis campaign. The presentation is available by registering at the website. My presentation was the tenth one on day one of the summit.

Follow Helen Slocombe on Twitter

The project team also won the trust’s award for most innovative team of the year - you can view our award video above - and the model has assisted the trust in developing a new discharge hub.

I am so pleased and proud that, as a new ward manager, I had the idea for the Dayroom to Doorstop project. It has turned out to be a true multidisciplinary team effort and helped to shape the trust's day room model and new discharge hub. I think it is true to say all staff are now embracing the model as part of everyday life on the ward. 


Helen Slocombe is a senior sister at Royal United Hospitals Foundation Trust, Bath

Jane Davies, senior nurse quality improvement, also contributed to this article

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