Improving the short-term management of patients with dementia admitted to hospital.

Abstract

Background: Approximately 25% of older in-patients in acute settings have dementia (Timmons et al., 2015). Patients with dementia are known to have poor health outcomes during acute hospital stays (Royal College of Psychiatrists, 2019). They also have negative experiences because of the focus of nursing staff on routines rather than the provision of person-centred care (Featherstone, Northcott, & Bridges, 2019). Aims: The overarching aim of this research is to broaden current understanding of how to improve hospital care for people with dementia. This is divided into three sections. The first aim of the study was to identify factors that affected the length of hospital stay of patients with dementia. The second aim was to develop two support bundles from interviews with staff and carers. The interviews were grounded in a systems approach, which involved looking at the policies, equipment, human interactions and the hospital environment (E. Edwards, 1972; Hawkins, 1987; Zecevic, Salmoni, Lewko, & Vandervoort, 2007). The third aim of the study was to ascertain the acceptability of the developed falls and discharge bundles through an online survey of members of staff, carers and people with dementia. Setting for the qualitative study: Six medical wards in one acute hospital. Methods and Findings: This mixed-methods study comprised of three phases. The first phase of this study investigated the impact of administrative, demographical, and clinical factors on the hospital stay of patients. This was completed using an anonymised UK hospital dataset, which was retrieved electronically. The study extracted two samples (i.e. main (n=14,771) and dementia sub-samples (n=1,133)). Both samples involved people who had not been readmitted and whose length of hospital stay was greater than 24 hours. The findings reported the Incidence Rate Ratios (IRR), which indicate higher length of stay. The results from the main sample in the service evaluation indicated a higher IRR (longer length of stay) for: a) discharge to a care home (IRR: 2.442) b) falls without harm and falls with minor harm (IRR: 2.640 and 2.049) and c) category 1, 2 and 3 post-admission pressure sores (IRR: 2.079, 2.218 and 2.148). For the dementia sub-sample, there was a higher incidence rate ratio for: a) discharge to a care home (IRR: 2.443) b) falls without harm (IRR: 2.486). Based on these findings, the qualitative research (i.e. second phase) which involved interviews with staff (n=20) and carers (n=32) explored how a systems based approach could help broaden current understanding on the reduction of falls and improving the discharge process. The first theme that emerged from the qualitative study was falls (this looked at issues such as the causes of falls and techniques used in the prevention of falls). The second theme was people in relation to falls. This theme revealed that family members, patient characteristics (e.g. frailty) and staff factors (e.g. teamwork) needed to be considered if falls are to be reduced. The third theme centred on the environment in relation to falls. This theme focused on topics such as: staffing levels, the transfer of patients between wards, dementia-friendly initiatives (e.g. colour schemes) and the use of mobility aids. The fourth theme was discharge planning. This theme for example, included making sure that appropriate funding arrangements had been discussed alongside the facilitation of preadmission visits to care homes by appropriate relatives. The fifth theme considered people in relation to discharge planning. This theme looked at factors such as the importance of teamwork and the involvement of family carers in the discharge process. The last theme focused on the environment in relation to discharge planning. This theme looked at subjects such as the use of medical equipment and meetings with hospital staff to discuss discharge arrangements. The final phase of the study involved an online survey to ascertain the acceptability of the falls (n=14 for hospital survey and n=38 for Join Dementia Research Survey) and discharge support bundles (n=3 for hospital survey and n=14 for Join Dementia Research Survey). The quantitative and qualitative findings from this phase indicated that staff, carers and people with dementia agreed with its contents. The bundle is now ready for evaluation in future work. Conclusion: This thesis has made an original contribution to knowledge by demonstrating that a systems approach could help to improve the current operandi to dementia care in the acute setting. The online survey revealed that people with dementia, carers and staff found the contents of the falls and discharge support bundles as acceptable.