Extended length of stay and related costs associated with dementia in acute care hospitals in Ireland

OBJECTIVE

To estimate the additional impact of dementia on in-patient length of stay (LOS) and related costs in Irish acute hospitals. Both principal and secondary diagnosis effects are estimated and valued.

METHODS

This is a cross-sectional study based on administrative data collected on all public hospital in-patient discharges in Ireland for people aged 65 years and older in 2019. Coarsened exact matching (CEM) was undertaken to account for observed confounders between dementia and non-dementia groups, while generalised linear modelling (GLM) was used to compare differences in LOS.

RESULTS

Patients with a principal diagnosis of dementia spent on average 17.5 (CI: 15.42, 19.56; p < .01) d longer in hospital than similar patients with no principal diagnosis of dementia. LOS was 6.7 (CI: 6.31, 7.14; p < .01) d longer for patients with a secondary diagnosis of dementia compared to similar patients with no secondary diagnosis of dementia. The additional annual cost of care for patients in hospitals with a secondary (principal) diagnosis of dementia was €62.0 million (€13.2 million).

CONCLUSIONS

This study highlights the economic impact of extended LOS for patients with dementia in Irish acute hospitals. Addressing specific dementia-related needs of people in hospital is likely to optimise resource use and decrease health care costs in acute care settings.

Variations in Rates of Discharges to Nursing Homes after Acute Hospitalization for Stroke and the Influence of Service Heterogeneity: An Anglia Stroke Clinical Network Evaluation Study

Nursing home placement after stroke indicates a poor outcome but numbers placed vary between hospitals. The aim of this study is to determine whether between-hospital variations in new nursing home placements post-stroke are reliant solely on case-mix differences or whether service heterogeneity plays a role. A prospective, multi-center cohort study of acute stroke patients admitted to eight National Health Service acute hospitals within the Anglia Stroke and Heart Clinical Network between 2009 and 2011 was conducted. We modeled the association between hospitals (as a fixed-effect) and rates of new discharges to nursing homes using multiple logistic regression, adjusting for important patient risk factors. Descriptive and graphical data analyses were undertaken to explore the role of hospital characteristics. Of 1335 stroke admissions, 135 (10%) were discharged to a nursing home but rates varied considerably from 6% to 19% between hospitals. The hospital with the highest adjusted odds ratio of nursing home discharges (OR 4.26; 95% CI 1.69 to 10.73), was the only hospital that did not provide rehabilitation beds in the stroke unit. Increasing hospital size appeared to be related to an increased odds of nursing home placement, although attenuated by the number of hospital stroke admissions. Our results highlight the potential influence of hospital characteristics on this important outcome, independently of patient-level factors.

National clinical programmes in the Republic of Ireland: a qualitative study of acute hospitals

Background

The national clinical programmes (NCPs) were established in 2010 to achieve three objectives, namely: improve quality, access and cost effectiveness. Limited research exists on their implementation in the Republic of Ireland (ROI). This qualitative study identified key stakeholders' perceptions on (a) implementation thus far, and (b) conditions perceived necessary for implementation in acute hospitals.

Aims

The overall aim of this research was to undertake an in-depth study to explore from the perspectives of key stakeholders, their perceptions on implementation of the national clinical programmes, thus far, in relation to three overarching objectives (to improve quality, access, cost effectiveness) and what are the conditions necessary for their implementation in the Republic of Ireland's acute hospitals.

Methods

Twenty participants were interviewed using face-to-face audio-recorded semi-structured interviews. Transcribed data were coded and analysed, and a number of themes emerged from the dataset relating to the study aims.

Results

Implementation was perceived as being inconsistent. Outcomes were identified as: best practice guidelines, models of care, protocols, pathways; education & training; new services; improved discharges; improved patient outcomes; reduced length of stay; timely access; reduced waiting lists; cost effectiveness and other intangible outcomes. Sixteen conditions, under four themes, were perceived necessary for implementation, namely: Governance - structure, audit & monitoring, senior management support, accountability, and clear objectives and expectations; Communication - visible face-to-face engagement, internal awareness, and external awareness; Leadership - programme level, national level, hospital level, and professional level; Resources - budget, staff, information technology, training, skills, and competency.

Conclusions

This study adds to the existing limited body of knowledge on implementation of the NCPs in the acute hospitals in the ROI while contributing to the wider international literature in this area. The study provides hitherto unreported knowledge on the conditions that are perceived necessary for implementation. Novel in the ROI context is the perceived necessity to condense the number of NCPs, placing greater emphasis on (a) the need to structurally integrate the NCPs across the continuum of care, and (b) the importance of communication through visible face-to-face engagement. This study concludes that significant progress has been made by the NCPs towards meeting the objectives, albeit to varying degrees. There is a strong perception that the NCPs should remain, and that addressing the conditions perceived necessary for implementation in the areas of governance, communications, leadership and resources by both top-down senior health officials and bottom-up front-line hospital staff would significantly enhance the ability of the NCPs to meet objectives and implementation. It provides the ROI health services with valuable information to inform future reform, strategic planning and NCP implementation.

Hospital-Level Variations in Rates of Inpatient Urinary Tract Infections in Stroke

Background and purpose: Urinary tract infection (UTI) is one of the most common complications following stroke and has prognostic significance. UTI rates have been shown to vary between hospitals, but it is unclear whether this is due to case-mix differences or heterogeneities in care among hospitals.

Methods: A prospective multi-center cohort study of acute stroke patients admitted to eight National Health Service (NHS) acute hospital trusts within the Anglia Stroke & Heart Clinical Network between 2009 and 2011 was conducted. We modeled the association between hospital (as a fixed-effect) and inpatient UTI using a multivariable logistic regression model, adjusting for established patient-level risk factors. We graphically and descriptively analyzed heterogeneities in hospital-level characteristics.

Results: We included 2,241 stroke admissions in our analysis; 171 (7.6%) acquired UTI as an inpatient. UTI rates varied significantly between the eight hospitals, ranging from 3 to 11%. The hospital that had the lowest odds of UTI [odds ratio (OR) = 0.50 (95% confidence interval (CI) 0.22–.11)] in adjusted analysis, had the highest number of junior doctors and occupational therapists per five beds of all hospitals. The hospital with the highest adjusted UTI rate [OR=2.69 (1.56–4.64)] was tertiary, the largest and had the highest volume of stroke patients, lowest number of stroke unit beds per 100 admissions, and the highest number of hospital beds per CT scanner.

Conclusions: There is hospital-level variation in post-stroke UTI. Our results suggest the potential influence of service characteristics independently of patient-level factors which may be amenable to be addressed to improve the ultimate stroke outcome.

Practical strategies to help develop dementia-friendly hospital wards

Hospital stays can have significant negative effects for people with dementia. This article explores methods of improving dementia care in general hospital wards. Taking its starting point as the importance of person-centred care, it explores ways of improving the ward environment, meaningful activities, personal history work, involving carers, and identifying and treating delirium. Practical strategies are suggested in each of these areas. The article acknowledges that implementing change can be challenging in NHS settings where wards are understaffed, and time is precious. However, it encourages all nurses working in these settings to recognise the importance of person-centred care for people with dementia and to make even small changes that can have a significant effect.

The perceived and observed needs of patients with dementia admitted to acute medical wards

It is acknowledged that the needs of persons living with dementia admitted in acute hospitals are not always met. Previous studies have focused on the perceived needs of professional caregivers or family members whilst the voices of patients with dementia in acute hospitals have not been extensively reported. This may have contributed to the under-recognition of the needs of persons living with dementia. The aim of this study was to categorise the perceived and observed needs of persons with dementia admitted in acute medical wards and to explore whether these needs are being or have been met. Thirteen people with dementia in three medical wards, who could verbally communicate with the researcher, were purposively selected as research participants. Semi-structured interviews were conducted to elicit each participant's experiences of their hospital stay and whether their needs were perceived to have been/are being met. Moreover, routine care with the same participants was observed using Dementia Care Mapping. Maslow's Hierarchy of Needs was used as a framework to categorise care needs. Our findings demonstrate that basic needs such as toileting, feeding, drinking, continence and comfort were not always met. Moreover, the largest gap between met and unmet needs was found in patients who were either under constant observation or unable to communicate. Too much emphasis was perceived and observed to be given on what staff considered as safety needs at the expense of other needs. The patients' need for social contact and self-esteem such as dignity and respect were often ignored and this led to patients feeling devalued. Hospital staff have to be more aware of the holistic needs of patients with dementia in acute settings and the way care is delivered in order to make up for these unmet needs, thus facilitating person-centred care.

How to deal with violent and aggressive patients in acute medical settings

Dealing with violence and aggression is an area where health professionals often feel uncertain. Standing at the interface between medicine, psychiatry and law, the best actions may not be clear, and guidelines neither consistently applicable nor explicit. An aggressive, violent or abusive patient may be behaving anti-socially or criminally. But in acute medical settings it is more likely that a medical, mental health or emotional problem, or some combination thereof, is the explanation and usually we will not know the relative contribution of each element. We must assume that difficult behaviour represents the communication of distress or unmet need. We can prevent and de-escalate situations by understanding why they have arisen, identifying the need, and trying to anticipate or meet it. In these situations 'challenging behaviour' is much like any other presenting problem: the medical approach is to diagnose and treat, while trying to maintain safety and function. In addition, the person-centred approach of trying to understand and address psychological and emotional distress is required. Skilled communication, non-confrontation, relationship-building and negotiation represent the best way to manage situations and avoid harm. If an incident is becoming dangerous, doctors need to know how to act to defuse the situation, or make it safe. Doctors must know about de-escalation and non-drug approaches, but also be confident about when physical restraint and drug treatment are necessary, and how to go about using appropriate drugs, doses, monitoring and aftercare. There are necessary safeguards around using these approaches, from the perspectives of physical health, mental wellbeing, and human rights.

Recognition and clinical management of sepsis in frail older people

Sepsis is a common condition caused by the body's immune and coagulation systems being 'switched on' by the presence of infection, either through bacteria or viruses in the blood. If untreated, sepsis can be life-threatening and is a leading cause of death in hospital patients worldwide. However, awareness of sepsis is low. This article provides an overview of the important role played by nurses in acute hospital settings in the early identification and treatment of suspected sepsis in frail older patients, and in escalating the care and management of deteriorating patients. It also explores recommendations in the 2016 National Institute for Health and Care Excellence guideline on sepsis recognition, diagnosis and early management.

Oral hygiene and mouth care for older people in acute hospitals: part 2

Acute hospital admission provides an excellent opportunity to address poor oral health in older people, a group rarely seen by dental professionals and for who oral health activity in hospital is inconsistent and generally suboptimal. This two-part article explores oral hygiene and mouth care provision for older adults in acute hospitals. The first article presented the findings of a literature review exploring oral and dental disease in older adults, the importance of good oral health and mouth care, and the current situation. The second article explores clinical recommendations. A change in philosophy is needed to embed oral care as an essential component of holistic practice. More research is needed to determine the best ways to assess and treat oro-dental problems in older people, and promote and restore their oral health in hospitals. Great potential exists to innovate and develop new ways of providing care to this group.

Oral hygiene and mouth care for older people in acute hospitals: part 1

The oral health of older people in acute hospitals has rarely been studied. Hospital admission provides a prime opportunity for identification and rectification of problems, and oral health promotion. This two-part article explores oral hygiene and mouth care provision for older adults in acute hospitals. The first article presents the findings of a literature review exploring oral and dental disease in older adults, the importance of good oral health and mouth care, and the current situation. Searches of electronic databases and the websites of relevant professional health service bodies in the UK were undertaken to identify articles and guidelines. The literature shows a high prevalence of oro-dental disease in this population, with many known detrimental effects, combined with suboptimal oral hygiene and mouth care provision in acute hospitals. Several guidelines exist, although the emphasis on oral health is weaker than other aspects of hospital care. Older adults admitted to acute hospitals have a high burden of oro-dental disease and oral and mouth care needs, but care provision tends to be suboptimal. The literature is growing, but this area is still relatively neglected. Great potential exists to develop oral and mouth care in this context. The second part of this article explores clinical recommendations.

Experiences of using simulation in dementia education

This article describes the development of a simulation training day for multidisciplinary teams (MDTs) working on acute adult wards with the aim of improving their confidence in supporting people with dementia who are distressed. Recommendations are made for those who may be interested in delivering simulation training in their area of practice. Registered nurses, non-registered support workers and occupational therapists experienced in dementia care took part in a one-day simulation training pilot session that included three 'skill stations' with three patient simulation scenarios. A session at the end of the day was used to generate qualitative feedback and develop a strategy to advance this style of teaching. Feedback highlighted the need for further development of the skill stations and scenarios. The pilot showed that simulation training works well from an MDT perspective, but the content requires careful consideration in terms of stretching participants' abilities without causing high levels of anxiety.

Elements of a sustainable, competent, and empathetic workforce to support patients with dementia during an acute hospital stay: A comprehensive literature review

Internationally, there has been a focus on the development of acute hospital workforces to support and care for people with dementia. Recommendations and initiatives to improve person-centred care in acute hospitals have included: education and training, dementia-specific roles, clinical leads, and environment changes. The aim of this literature review is to understand the elements of a sustainable, competent, and empathetic acute hospital workforce providing person-centred care for patients with dementia. The following databases were searched for literature published in English from January 1, 2006, to August 1, 2016: CINHAL, MEDLINE, PsychINFO, PubMed, and Science Direct. A thematic analysis was applied to develop a meta-synthesis of the data. A total of 12 papers with a range of methodological approaches from various countries were included. Emergent themes were as follows: understanding the current workforce, implementation and evaluation of training, and exploration of new and existing roles. An important element was the sustainability of acute hospital workforces competent in dementia care, as studies highlighted an ageing nursing population and a high turnover of staff. Dementia awareness training was sustainable, although there was a lack of consistency in the length, content, and delivery, which had a viable impact on the provision of empathetic and person-centred care. The lack of consistency of training and specialist dementia roles restricts recommendations from a robust evidence base.

An Observational Study to Explore the Feasibility of Assessing Bereaved Relatives' Experiences Before and After a Quality Improvement Project to Improve Care of Dying Medical Inpatients

Although hospitals are the most likely place of death, the quality of care received by dying inpatients remains variable. This is concerning for both the dying person and their relatives, with poorer bereavement outcomes likely for those who perceived their family member suffered unduly. There is a real need to consider how this situation can be improved. This work was conducted with the aim of exploring the feasibility of including bereaved relatives' experiences as part of a larger project exploring the use of a care bundle to improve care of the dying inpatients. Fifty relatives of inpatients who had died previously in hospital were contacted by letter with a request for interview before the implementation of a care bundle for the dying, with a care bundle being a collection of care processes that are implemented together. After this project had been in place for 6 months, a further 50 families were contacted who had died on the bundle. Ten families responded initially to the first request and 10 the second, with the interviews based on the Quality of Dying and Death (QODD) tool and a final open-ended question. Although all families who agree to be interviewed completed the session, with regard to the QODD, some families indicated that they would rather talk than provide numeric scores. No major differences in the prescores and postscores were noted. When invited to share their experiences, without prompting, families spoke of consistent concerns that included communication, place of death, and symptom control. This work confirms that it is highly feasible to incorporate assessments of bereaved family members' opinions as part of the wider assessment of research into end-of-life care.

Role confusion as a barrier to effective carer involvement for people with intellectual disabilities in acute hospitals: findings from a mixed-method study

AIMS

To understand issues around carer roles that affect carer involvement for people with intellectual disabilities in acute hospitals.

BACKGROUND

There is evidence that a lack of effective carer involvement can lead to poorer health outcomes for people with intellectual disabilities, but there is a lack of insight into the reasons for poor carer involvement in acute hospitals.

DESIGN

Mixed methods in six acute hospital trusts in England (2011-2013).

METHODS

Electronic hospital staff survey (n = 990), carer questionnaires (n = 88), semi-structured interviews with hospital staff (n = 68) and carers (n = 37). Data were triangulated and analysed using a conceptual framework.

RESULTS

There was strong support for carer involvement among hospital staff, and most carers indicated that they felt welcomed and supported. However, an investigation of negative experiences showed that there were discrepancies in the perspectives of hospital staff and carers on the scope of 'carer involvement'. An important contributory factor to the effectiveness of carer involvement was the degree to which staff understood the importance of carer expertise (rather than simply carer work) and welcomed it. Carers' contributions to basic nursing care tasks could be taken for granted by hospital staff, sometimes erroneously.

CONCLUSION

The roles and contributions of carers should be clarified on an individual basis by hospital staff. The authors propose a new model to support this clarification. Further research is needed to assess the suitability of the model for patients with intellectual disabilities and other vulnerable patient groups.

Reconfiguration of acute care hospitals in post-socialist Serbia: spatial distribution of hospital beds

In the context of healthcare reforms in post-socialist Serbia, this research analyses the reconfiguration of acute care hospitals from the aspect of the spatial distribution of hospital beds among and within state-owned hospitals. The research builds a relationship between the macro or national level and the micro or hospital level of the spatial distribution of hospital beds. The aim of the study is to point out that a high level of efficiency in hospital functionality is difficult to achieve within the current hospital network and architectural-urban patterns of hospitals, and to draw attention to the necessity of a strategically planned hospital spatial reconfiguration, conducted simultaneously with other segments of the healthcare system reform. The research analyses published and unpublished data presented in tables and diagrams. The theoretical platform of the research covers earlier discussions of the Yugoslav healthcare system, its post-socialist reforms and the experiences of developed countries. The results show that the hospital bed distribution has not undergone significant changes, while the hospital spatial reconfiguration has either not been carried out at all or, if it has, only on a small scale. All this has contributed to overall inadequate, inflexible, inefficient, defragmented and unequal bed distribution. Copyright © 2016 John Wiley & Sons, Ltd.

Patient safety and hydration in the care of older people

Ensuring patients are adequately hydrated is a fundamental part of nursing care, however, it is clear from the literature that dehydration remains a significant problem in the NHS with implications for patient safety. The development of dehydration is often multifactorial and older age is an independent risk factor for the condition. However, the media often blame nursing staff for simply not giving patients enough to drink. This article discusses the scale of the problem in acute care settings and aims to raise awareness of the importance of hydration management and accurate documentation in nursing practice. It suggests that intentional hourly rounding may provide an opportunity for nurses to ensure older patients are prompted or assisted to take a drink.

Managing verbal agitation in people with dementia and delirium

Patients with dementia and delirium in acute hospitals can exhibit verbal agitation, but there is no research on rate of occurrence or how ward staff manage such behaviour. This service evaluation aimed to measure rate of occurrence of verbal agitation in confused older inpatients and understand the management strategies used by staff. An agitation inventory was completed daily by the nursing team for all verbally agitated patients on eight older person wards over two weeks. Six semi-structured interviews were conducted with staff and three hours of non-participant observations were undertaken. A mean 6% (13/223) of patients were verbally agitated each day. Management strategies included trial and error, distraction and engagement, reassurance, communication and familiarity. Staff did not adopt a systematic approach to care planning due to lack of training and support on the ward, as well as scarce resources in terms of staff, space and activities. Research is needed to develop and evaluate interventions that support staff to care for these patients.

Enabling hospital staff to care for people with dementia

This is the fourth and final article in a short series that presents case study examples of the positive work achieved by trusts who participated in the Royal College of Nursing's development programme to improve dementia care in acute hospitals. Dementia training in hospitals is often inadequate and staff do not always have sufficient knowledge of dementia to provide appropriate care. It can also be difficult for them to identify when patients with dementia are in pain, especially when their communication skills deteriorate. The case studies presented illustrate how two NHS trusts have worked to ensure that their staff are fully equipped to care for people with dementia in hospital. Basildon and Thurrock University Hospitals NHS Foundation Trust in Essex made dementia training a priority by including dementia awareness in staff induction across a range of roles and providing additional training activities tailored to meet staff needs. Nottingham University Hospitals NHS Trust focused on pain assessment, aiming to standardise its approach for patients with dementia. The pain assessment in advanced dementia tool was chosen and piloted, and is being implemented across the trust after a positive response.

Improving the hospital environment for people with dementia

This article is the third in a series presenting examples of the positive work achieved by trusts who participated in the Royal College of Nursing's development programme to improve dementia care in acute hospitals. The hospital environment is often disorientating for people with dementia and can be particularly distressing when a patient is admitted in an emergency. Subsequent ward moves can also be disruptive and confusing, especially if they take place out of hours. Two NHS trusts aimed to improve the experience for patients with dementia by addressing the physical environment along with practical aspects of care provision at different stages in the hospital journey. The Queen Elizabeth Hospital King's Lynn NHS Foundation Trust in Norfolk enhanced its emergency department environment by redesigning four bays and an observation area to be dementia-friendly. The hospital has supported these changes by providing dementia awareness training for all staff in these areas. Walsall Healthcare NHS Trust focused on minimising ward moves by implementing procedures to identify patients who should not be moved. Since introducing the new process, adherence has been good and there have been fewer ward moves.

Improving activity and engagement for patients with dementia

This is the second in a short series that presents case study examples of the positive work achieved by trusts that participated in the Royal College of Nursing's development programme to improve dementia care in acute hospitals. Staff often think that there is insufficient time to get to know patients and carers, especially with large and challenging workloads. Combined with a lack of activities and stimulation for patients with dementia in hospital, this can result in poor engagement and a disconnect between staff and patients. To improve these relationships and give staff more time with patients, Cambridge University Hospitals NHS Foundation Trust has introduced bay nursing for patients with dementia, where one nurse is responsible for monitoring a bay alongside a healthcare assistant for an entire shift. Part of Betsi Cadwaladr University Health Board, Glan Clwyd Hospital in north Wales has focused on improving stimulation by creating an activity room with a specially trained activity worker, providing a relaxed and friendly setting where patients with dementia can take part in a range of activities and have lunch together.