Improving the quality of dementia care in hospital

The Alzheimer's society estimates there are approximately 850,000 people with Dementia in the UK, which is projected to rise to over 1 million by 2025. Consequently, improving Dementia care is considered a national priority. Research has shown that individuals with dementia (IWD) tend to stay in hospital longer, have worse medical outcomes, and experience poor care more frequently than their peers without dementia. Research has also shown that caregivers of IWD are generally dissatisfied with the experience of inpatient care, and that staff in hospitals often feel they are ill-equipped to cope with patients who have dementia. The variation in quality of hospital care across England is such a pressing issue the Alzheimer’s society has launched a dedicated “Fix Dementia Care” campaign

Individuals with dementia are particularly vulnerable at points of transition such as moving from home to hospital. In addition to the medical condition that necessitates admittance to hospital, this transition is frequently associated with a change over in primary caregiving responsibility from informal (ie. family) to formal care providers (ie. healthcare staff). While formal caregivers are able to provide skilled medical intervention, there is a risk that important information regarding the social and psychological needs of a patient maybe lost or diminished in the process of that handover.

With that in mind, it is fairly intuitive that the solution is to make sure formal and informal caregivers engage in a dialogue (which includes the patient where possible) to communicate this information to one another. However, in the context of a busy emergency department, a huge variety of barriers to communication can arise which interrupt that process. Some of these things are related to the individuals involved; for example language ability and interpersonal skills. However, the vast majority of these communications barriers are the result of issues which have to be addressed on a systemic level such as: understaffing in A&E causing time pressures for staff taking histories; medical emergencies which demand immediate intervention; and a physical environment which makes communication challenging because of excess noise, lack of privacy, or significant activity which can be disorientating or unsettling for individuals with dementia.

One way to address these challenges is to use a facilitated communication tool, such as a form (potentially similar to the 'This is me' booklet developed by the Alzheimer’s Society but specifically designed for use in the emergency room setting) which can be filled out together as a standard part of an admissions process for individuals with Dementia, or a checklist which staff use to ensure that relevant psycho-social information has been gathered verbally from the patient or caregiver. Formalizing and standardizing the process can make it easier to ensure consistency in quality of care, and establishing the practice as routine means that staff providing care will be more able to estimate how long it will take to gather psycho-social history, and share information in standardized format between different locations of care.

Inevitably there may be some resistance to the introduction of new procedures-especially those that may be perceived as adding extra work to things that are relatively intuitive and routine. However, the evidence from other patient safety initiatives that have used facilitated communication – for example the Safe surgical checklist– is unequivocally clear, it works! The intent of introducing an intervention to facilitate communication in A&E is to support staff and enable them to provide the best quality of care by acknowledging and attempting to mitigate the systemic and environmental barriers which make effective communication challenging.

Over the course of my PhD, I will be working with healthcare staff, caregivers, and patients with dementia to develop an intervention that can be used in A&E departments to facilitate communication. This research is part of a broader program of work on transitions in Dementia care which is taking place at University of Bradford.

Courtney Shaw, Doctoral Research Student, .