Leading change

The Dementia, Learning Disability and Patient Experience Lead Nurse for Sandwell and West Birmingham Hospitals NHS Trust provided leadership to develop the Dementia, Delirium and Distress pathway and establish a clinical multi-disciplinary team to provide support, guidance and education to Trust staff to improve patient outcomes and the experience of patients with cognitive impairment.

Where to look

Nationally it is recognised that patients with dementia, delirium and learning disabilities have poorer outcomes during admissions to hospital. The Dementia, Learning Disability and Patient Experience Lead Nurse identified unwarranted variation in the care and treatment of cognitively impaired patients through the following concerns:

• higher than expected levels of restrictive 1:1 patient observations due to behaviours that were perceived as challenging
• avoidable delayed discharges from acute services and higher numbers of readmissions to the hospital
• variation in the knowledge to support patient-centred assessments and care planning during admission.

What to change

Department of Health (2014) guidance advises that by adopting a positive and proactive response to people who may have behaviours that present as challenging, service users, and staff safety, dignity and respect can be maximised. At Sandwell and West Birmingham Trust, the nurses identified through listening to experiences of patients, carers and staff recognised that patients with cognitive impairment related to Dementia, Delirium or Learning Disabilities were more likely to experience distress during admission to hospital than other patient groups. They identified that by using person-centred risk assessments with this patient group, distress could be avoided or dramatically reduced and therefore in turn the risks posed.

The Lead Nurse established a clinical multidisciplinary leadership team. This team led the development of a Dementia, Delirium and Distress ‘Triple D’ (DDD) pathway. The aim of the project is to support and embed compassionate and person-centred care, managing patients’ needs holistically, not by diagnosis to avoid distress.

How to change

The leadership team included carers, to identify how services could better meet the needs of patients. The improvement of staff knowledge and confidence was key to better patient care and outcomes. The Triple D project included work programmes in the following areas:

• Patient-centred Care
• Education in Dementia, Delirium and Distress
• Carer Involvement
• Identification
• Champions
• Therapeutic Activity

The clinical multidisciplinary team provided leadership, role-modelling, educating and support to staff. Developing how staff changed their approach to patients with behaviours perceived as challenging. The team work to empower other staff members to become leaders of change. The team also promoted initiatives such as “nothing about me, without me”, “All About Me”.

The pathway also included:

• Supporting earlier identification of patients by using the ‘Triple D’ logo
• A 30 minute observation chart and development of patient-centred care plans
• John’s Campaign to ensure carers are involved within their loved one’s care where they wish to be.

The DDD pathway enables healthcare professionals to identify each patient’s individual needs, develop a holistic approach to care, enhance patient-centred care, identify trigger factors for patients through 30 minute observation time and begin to support patients and their families to promote wellbeing and minimise avoidable risks involved, such as falls.

Adding value

The Lead Nurse monitored effectiveness monthly and reported to the corporate team. The report identifies areas of strengths and areas that required more support and by gathering data it enables the team to evidence that the DDD service is highly valued and extremely beneficial.

Better outcomes – Qualitative and quantitative data gathered to date shows approximately 120 patients have been seen by the team monthly. Approximately 85 patients are commenced on the Triple D pathway monthly and they have seen a positive reduction in avoidable bed moves and possible associated distress.

Better experience – The team’s work is increasing patient and carer satisfaction and achieving positive outcomes for patients with their sense of self at the heart of their care. The impact of the DDD service for patients, their families and carers has been a great success.

Examples of feedback the team have had are:

•  “Thank you to the Dementia team for all of your care, support and involvement in my Dad’s care. His needs were identified and met due to the help of the team. I cannot thank you enough for all that you have done for my Dad”.
• “The nurses in this team have looked after me very well. After receiving the unexpected news of the loss of my daughter they were here on hand to help me. I don’t know what I would have done without them”.
• “Thank you for all the help and support looking after my brother. I have been through a terrible time with my brother this past month whilst he has been in hospital. The dementia nurses have supported me and my brother throughout the whole journey. I am ever grateful for all of the help, support, phone calls and a shoulder to cry on when I have needed it the most”.

Better use of resources – Since April 2017, they have reduced the need for restrictive 1:1 observations by 85%. This has been as a result of the proactive and positive responses used by staff minimising distress in patients on the pathway and through the holistic care planning used to promote general well-being of this individuals.

Challenges and lessons learnt for implementation

Key areas of learning identified are:

• Emphasis on ‘need’ rather than risk or diagnosis
• Person-centred service and a change in the Trust’s culture
• Strong emphasis on training and education
• Identifying key stakeholders early, like-minded staff within clinical areas to work as champions and promote the new way of working
• Change can be difficult. The team set out to remain positive and show that things can change and that there can be a difference.

Due to the successes of the programme the clinical team are currently in the process of expanding. The team will be recruiting a healthcare assistant and full-time trainer to provide the much needed education within all clinical areas including the care homes and step-down areas patients may be transferred to, and a BME need to ensure we are able to meet the needs of a multicultural community.

Staff feedback highlighted they would like extra training to support them in caring for patients with dementia, delirium and distress. They are currently in the process of arranging extra training with Alzheimer’s Society to educate and support all staff within the Trust.

Find out more

For more information contact:

• Gemma Diss, Lead nurse for Dementia, Learning Disabilities and Patient Experience, gemmadiss@nhs.net