Within this assessment, I will be using the BEET Tool workbook, which will be shown at the end, and a report on what I was trying to accomplish and how it went with other staff members. Due to moving and being sick, I implemented half of this task at Mater Queensland Hospital before moving and then continued the rest of the process distance. What I noticed within working the different sections of day surgery, theatre, recovery, and discharge was the same problem, anxiety from patients with dementia and the carers within waiting times and staff not knowing that the patient has a declined cognition – which leads to a delirium post-operative. Alzheimer's Australia SA 2014 – states that nearly half of hospitalized people with dementia do not have ‘dementia’ recorded as a diagnosis. It is then also shown not to be well documented in carer notes, The Australian Institute of Health and Welfare (AIHW, 2013) states that ‘dementia’ when present was documented in the notes less than half the time.
A common reason for a person living with dementia to need to be hospitalized or surgery is falling over and needing hip or knee surgery, chronic pain, respiratory infection, urine infection, or delirium, Draper et al 2011 state that 30 to 50% of total patients admissions in acute care have a cognitive impairment, this is also backed up by Travers et al 2013 and Christi & Cunningham 2011. Hospitalized people with dementia are at increased risk of developing delirium. Rates of delirium in hospitals are estimated as 10-31% at admission, 3-10% during hospital episodes, and 70% when in intensive care units (Draper et al 2011, Sampson et al 2009). This information hit me right at home and made me start this project if we can prevent delirium from happening at admission then that simple task can reduce the amount of time a patient with delirium is in the hospital. I used this information with all the staff to show them how important our process of admitting a person into surgery can affect the outcome for the patient.
Ensuring that the staff I worked with really understood what delirium meant, we had a little game on a day when the hospital had gone completely blacked out and the generator did not work. This game involved people having an eye patch on or wearing someone else glass and trying to find some simple items that I had placed in simple places for them to find, Staff found that it was difficult to keep attention on what the task was with the area being darkened and losing their eyesight, I then explained that delirium is a disturbance of consciousness, attention, cognition and perception that develops over a short period of time, and usually fluctuates during the course of the day with orientation and awareness ( America Psychiatric Association, 1999) just like if we removed the eye patches or had the power come back on staff would find it easier to do the task that was set in front of them. I then explained about my university assessment and the puzzle I was going to look at implementing. Due to good repour with the staff they were happy to try the puzzle with chocolates on board.
Delirium is a serious medical problem and patients with Dementia are most likely at risk of developing delirium during periods of illness or hospitalization. The rates of delirium in older patients are much higher, between 22% to 89%, with the highest rates reported among those with co-morbidities such as acute fracture and dementia. (Fick, Agostini & Inouye, 2002). However, health professionals experience difficulty in recognizing the presence of delirium (Flacker & Marcantonio, 1998, Hustey, Meldon, Smith & Lex 2003, Inouye, Foreman, Mion, Katz & Cooney, 2001, Meagher 1998), identifying the predisposing risk factors, and in differentiating between delirium and other conditions such as dementia (Cole, 2004). As the population ages, the age and acuity of hospitalized patients will increase and the prevention or early detection of delirium will become an increasingly important issue, particularly for those patients with pre-existing dementia.
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It is estimated that approximately 15% of older people have symptoms of delirium on admission to the hospital and up to a further 40% are estimated to develop this condition on hospitalization (Minister’s Advisory Council 2006), With this information in hand I had spoken to my Nurse unit manager (NUM) about the puzzle that I was looking at doing with the facility and explained the little game I played with the staff and how we can improve our process on admitting a patient to the hospital who are at risk of delirium or already have a diagnosis of dementia. The information that really got my NUM on board was the incidence of delirium may also increase across the different settings and could eventually be implemented across the hospital, an estimated 40.5-55.9% incidence of patients 65 years and older undergoing hip surgery, to 5-10% of emergency department patients, to 83-87% incidence of delirium in patients admitted to intensive care units. (Australia Health Minister’s Advisory Council, 2006)
I spent some time with my NUM discussing the puzzle and how it would help improve the anxiety of people waiting for surgery. It took a few meetings with my NUM due to new management and a lot of changes about to happen, we had to make a decision together on the best timing to start the puzzle as she believed that it would be beneficial for the patients and staff throughout the hospital. We decided that I would spend time with the admission staff first, as they were the first people on the floor. I organized a meeting with staff and explained to them what I was trying to implement and explained the puzzle, to start open discussion. I reminded them that older patients admitted to the hospital commonly exhibit changes in behavior and cognition. Frequently labeled as ‘confused’ and usually this label continues throughout their stay but does little to explain why they are confused or if they do have a diagnosis of dementia.
Generally, hospital is a daunting experience for anyone being admitted, I know personally when I have had to go to an emergency that my anxiety levels for waiting increase because I’m in pain, this increases anyone’s anxiety and then puts cognitive impairment on top makes it a lot hard for patient to deal with the institutional appearance. With large corridors that just look the same, multiple exit and fire signs, lots of people running around in the same clothing, a nosey environment, and bright lights when it's 3 in the morning. All these factors have been shown to increase anxiety in a person and even increase more for someone living with dementia. (Flemming & Purandare, 2010)
With all this information, knowledge, and empathy we were able to look at different processes that we may have in place that could assist with this puzzle. We decided as a team to look through the process that we had in place for people living with diabetes as a group we decided that it would be easier to adapt the same process for people living with dementia. This process is that the specialist actually asks the patient and carer if there is a diagnosis of dementia or cognitive impairment before surgery is booked, if there is a diagnosis then the pre-op nurses will either see the patient in the clinic or speak to the carer on the phone to ensure that most of the admission forms are filled in and that the carer has all information that is needed before the day. We also place the patient on the top of the list after the diabetics, so they are not being operated last or waiting in gowns for 4 hours or more. This was written up by all nursing teams and then discussed with the nurse unit manager and regular doctors who operate on our elderly customers. All parties were happy to give it a trial. At this stage, the project is still in its trial stage and I had to let another staff member continue running the puzzle when I was moving, but they did keep me in contact and discuss the puzzle with me and said that it seemed to assist with the anxiety levels and patients with dementia are finding they are in and out much quicker and less likely to need to stay overnight due to delirium or anxiety. Staff are starting to understand that if delirium is undetected or misdiagnosed, the changes in cognition and orientation may be prolonged and impact the patient’s future quality of life long after they have been discharged from the hospital.
There have been many challenges with this puzzle, for me personally with moving and having to leave the puzzle in another staff member's control because the staff were happy to improve how patients in general are admitted. Another challenge I found was knowing where to start, yes I knew what I wanted to accomplish but when a facility is going through many changes where do you start another change, I was blessed as I have good repour with staff, from doctors to nursing staff that they were all happy to assist with my university assessment, what I do think is exciting is that they started to understand how poor we look after our elderly patients who have a diagnoses of dementia or at risk of developing a delirium all due to being admitted.
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