If you are walking through the corridors of Northeast Health Wangaratta (NHW), don’t be surprised if you come across staff and patients playing cards together, reading the newspaper or even painting their fingernails. It’s all part of the hospital’s approach to caring for patients with delirium and dementia.
When the hospital was looking at ways it could improve care for older people, they realised there was a need to improve the way patients with dementia and delirium, and associated behavioural problems were being cared for, especially in the acute wards.
Delirium is common in older patients, and can have serious consequences including longer recovery times and functional decline. People with delirium appear confused and sometimes become hyperactive and agitated. Patients with both dementia and delirium are at particular risk of harm.
“I saw a volunteer with a patient the other day and they had a doll and were folding nappies. She was very settled, whereas the day before she had needed [one-on-one care].”
Nicola Coats, Best Care for Older People (BCOP) Project Officer and Jonelle Hill-Uebergang, Deputy Director of Nursing at NHW decided to take a three pronged approach to addressing the needs of patients with delirium and/or dementia: they developed a new way of documenting behavioural symptoms in order to provide more effective interventions; they revised the way one-on-one nursing care was provided to high needs patients and they created a library of activities for staff and visitors to use with patients. All these initiatives interrelate and provide a framework for best practice care for older people with delirium and/or dementia.
Patients with behavioural issues or showing signs of confusion were often provided one-on-one care (sometimes called ‘specialling’). Staff providing this care were not always trained in caring for patients with dementia and delirium. It was not uncommon for them to understand their job to be preventing the person getting out of bed, and beyond that having little interaction with them.
The hospital now has a guideline in place for providing one-on-one care. A handbook developed by Nicola is given to all staff providing one-on-one care, detailing information about the signs and treatment of delirium.
Nicola also developed a behaviour chart for use with agitated or hyperactive patients with dementia or delirium. The patient’s level of agitation and pain is documented on an hourly basis, allowing clinical staff to look for patterns in behaviour and adjust the patient’s care to avoid triggers and improve outcomes. The chart also includes information on possible causes for behavioural problems and appropriate interventions, including whether one-on-one care should be provided. The behaviour chart is now used throughout the acute wards.
Patients with dementia and/or delirium, especially if they become agitated or upset, often need to be distracted. The diversional activities library that has been developed is an innovative way of helping to manage patient symptoms while in the unfamiliar environment of hospital and during a severe illness. The idea behind the library is that if an agitated patient is given a task or activity, it can help calm them, by occupying and distracting them. The library includes items such as a toolbox filled with screws, nuts and bolts, realistic looking baby dolls and dogs and cats, games and playing cards, films on DVD and a manicure kit. There are also ‘fiddle mats’ sewn by a volunteer, designed to keep fingers busy with zips, buttons and different textures of material.
Staff, family members and other visitors, and volunteers all have access to the library and are encouraged to find appropriate activities to share with the patient. Knowing about the person’s interests, history and habits helps to find a suitable activity.
Nicola says when they first started introducing it she was unsure whether staff would accept it as a clinical intervention. “I got into work one day and got a call that ‘we’ve got an agitated patient up here in surgical – can you bring up your nuts and bolts’. My heart was in my mouth and I walked up there with my little toolbox and a few other things but it worked. I just said, ‘Bob, these things have got all muddled up here, can you give me a hand sorting them?’ This man had pulled out his IV, was trying to get his catheter out, very agitated – and it worked… the staff see this.”
Family members, friends and volunteers have also found it helpful to have some direction about how to interact with a person who may be behaving quite differently than usual. It can be frightening to see a love one confused and worked up, and being able to use activities to calm a person can be reassuring for both parties. Even under the best of circumstances, having a focus during a visit can be helpful. Playing cards, reading the newspaper or watching a film can pass the time and introduce a sense of normalcy and routine into the hospital stay.
This can also help keep patients calm and occupied, reducing the need for further interventions. Jonelle gives an example: “I saw a volunteer with a patient the other day and they had a doll and were folding nappies. She was very settled, whereas the day before she had needed [one-on-one care].”
"The other day I was in the rehab ward and the unit manager had brought a little motor in because there was a patient there that was an old mechanic and he had started to go into a delirium... He took this motor apart and put it back together… and that kept him on track, as well as medication."
These strategies all work together and all have a person centred approach at their core. Each intervention works best with input from patients (where possible) and their families and carers. Understanding a person’s usual routine, what they enjoy and what upsets them, their background and interests all enhance the effectiveness of the strategies used and work towards ensuring the best possible outcomes for the patient.
Jonelle is full of praise for the way Nicola worked with staff and led by example. “Once Nicola started to educate and give them tools, and give them strategies, they were hungry for it, because they could see it was actually going to make their day easier... She demonstrated that [these strategies] work by practicing them, so people are now using their own initiative.
The success of these strategies, the hard work of staff in championing their use and the dedication of the volunteers who now maintain the resources all contribute to this being an initiative that has now become part of the culture of care at NHW.