Leading change

A nurse in the Post-Anaesthetic Care Unit at Nottingham University Hospitals NHS Trust (NUH) led on a programme of work to minimise the experience of distress for patients. The nurse developed a programme to provide tailored resources and techniques to support a patient’s recovery post-anaesthesia, to minimise distress, improve outcomes and experience of care.

Where to look

Alcorn and Foo (2016) reported that up to 850,000 people in the UK are currently living with dementia, with this set to increase to 1 million by 2025. As the incidence of dementia approximately doubles for every 5-year increase in age, and older patients are increasingly presented for anaesthesia and surgery, anaesthetists frequently encounter patients with dementia in everyday clinical practice. The Association of Anaesthetists of Great Britain and Ireland (AAGBI) (2018) state that there is no national guidance on how people with dementia, and their relatives/carers, might best be supported through an episode of surgery and anaesthesia. Edis (2017) indicated that caring for patients with dementia emerging from general anaesthesia in the recovery room can at times present with added complexity. The nursing team in the Post-Anaesthetic Care Unit identified that there were not any specified local or national guidelines to support best nursing practice in this situation.

The Post-Anaesthetic Care Unit (or ‘recovery room’) nurse at NUH identified unwarranted variation in the nursing staff’s capacity and capability to provide a space for dementia patients that was calm, familiar and able to effectively support patients with dementia recovery. There was an opportunity to minimise sedation and to increase the use of evidence-based distraction tools and techniques to support patients with in their care, providing a more holistic, nurse-led care pathway. This would present an environment that supports better patient care and better patient experience.

What to change

The nurse identified a project which included implementing 3 key changes:

• Improving the provision of physical resources to support distraction techniques for dementia patients;
• Increasing patient information sharing across the ward as well as with theatre and recovery staff using the ‘About Me’ documents. Typically, this form is completed and maintained on the ward, however staff and patient experience would be enhanced if this was shared with both theatre and recovery staff. The documents include patient-centred information such as ‘what the patient likes to be called’ and ‘what may support the patient at times of distress’;
• Enhancing educational support for staff who support the patient on their ward to theatre and recovery process. The education programme included nursing and care staff, as well as hospital theatre patient escorts. Face-to-face and e-learning packages were designed to support the patient and keep them calm throughout their nurse-led care pathway.

How to change

The nurse led on three specific areas to support improvement on the ward and Trust more widely:

• The dementia care resource trolley now contains a CD player, literature, disposable headphones and a selection of classic music CDs. NUH charity funding was negotiated to support the introduction of these therapeutic resources;
• Enhanced partnership working pathways. The nurse worked with the senior nurses on the trauma and orthopaedic wards at NUH, creating a handover pathway that included the ‘About Me’ document;
• Supported nursing and care staff to access e-learning tools on dementia care. This included liaison with the Trauma and Orthopaedic staffing teams to advocate that the learning became a routine element of Continued Professional Development for nursing staff in their care provision for patients with dementia.

Adding value

Better outcomes – After implementing these changes across the ward, nurse-led care has increased and patients are calmer, which is associated with the introduction of appropriate resources for patients to use and a reduction in sedation. There is a positive and holistic approach to care which is enabling less invasive care whilst also enhancing staff understanding of techniques for working with patients with dementia. The dementia care resource trolley has been utilised many times already in recovery and the staff are enthusiastic about the impact it is having on outcomes. It has also raised awareness of dementia and the need to provide adapted care to this vulnerable group of patients. The trolley of resources has received interest from other staff groups and different areas across the hospital.

Better experience – Positive feedback has been received for this simple intervention. Staff could write comments in the feedback book that accompanied the trolley. Staff were made aware these comments would be used to evaluate the project and could be published. A sample of the comments received were:

• “I used music therapy on an elderly lady with dementia. Initially she was very agitated but seemed to calm with a combined intervention of ‘twiddlemuff’, music and having her daughter present.”
• “I used two ‘twiddlemuffs’ for two different patients today. One agitated and the other just pulling at lines and cables. Both were very effective.”
• “I used the CD player … very effective in calming the patient who had known dementia …music was the biggest calmer. Worked a treat!”
• “When we played the music … she calms and it soothes her mood.”

Better use of resources – More optimal use of anaesthetic drugs whilst also releasing the time of anaesthetists has been noted. The optimal use of anaesthetic drugs has also anecdotally resulted in more patient-centred follow-up care when they are in the ‘recovery room’, with increasing numbers not needing to awake from a sedative, associated with better outcomes for patients.

Challenges and lessons learnt for implementation

• It is important to remember that a small-scale change can make a huge impact;
• Identifying the unwarranted variation in the first place can often be the hardest part of service improvement but is worth it when trying to measure the impact of your work.

Fin out more

For more information contact:

• Helena Edis, Recognition for Excellence Lead, Magnet Programme Office, Nottingham University Hospitals NHS Trust, helena.edis@nuh.nhs.uk