Navigating care for the older person with behaviours associated with dementia, delirium and depression
Summary
This project was designed to help bridge knowledge gaps identified in collaboration with staff to optimize the care of older adults with behaviours associated with dementia, delirium and depression. Utilization of the RNAO Best Practice Guidelines; Patient and Family Centered Care, Delirium, Dementia and Depression, and Care Transitions, was the foundation for the fellowship. The fellowship came at a time of organizational realignment, launch of a new Strategic Plan, the need for cultural change, post COVID recovery, and preparation for the new South Niagara Site opening in 2027which will be a center of excellence in geriatrics. The patient population was defined as individuals 65 and up, currently accounting for 65% of all inpatient days and the longest length of stay in hospital related to medical and social complexity. The fellowship started with a gap analysis and environmental scan of current practice, culture of staff, knowledge of clinical tools, and documentation practices across all 5 Niagara Health sites, on medical, surgical and complex care units to provide improvement in patient-centered care for the older adult. 320 Charts were audited for patients admitted to hospital over the age of 65. Audit indicated significant areas for improvement in documentation process, the increased need for non-pharmacological interventions for delirium prevention and management, knowledge on delirium screening, as well, review of policy/procedure and documentation for emergency restraint use. Upon completion of the chart audits, a review of current approved documentation tools was completed. Currently, forms are printed from an online database either as individual or Z-packs. A Z-pack for “older adults with responsive behaviours” was created, making it easy for staff to access/print all documents required to provide patient-centered care. Along with the Z-pack, creation of a process flow diagram for our geriatric population was created. This flow diagram is to become a teaching tool to help staff accurately assess and prioritize interventions for admitted older persons with risk or diagnosis of 3Ds. The current non-pharmacological strategies for delirium prevention and management tool was also revised. The form was expanded to include more high value interventions and to increase nurse and allied health team accountability. The new clinical tools were presented to the Nursing Advisory Committee and approved before being submitted to the forms committee for release to the organisation. Huddle talks and rounding on inpatient units was completed to introduce new documentation tools and to highlight the importance of documentation in such a complex population. A comprehensive sustainability plan was created with interprofessional teams across NH.
The overall learning goal of this fellowship was to work to implement BPGs and develop both professionally and personally in an organization which focus’ on the care of the older adult. As a Geriatric Assessment Nurse it is imperative to lead by example and build capacity with teams across an organization to help provide optimal care for older persons with behaviours. By optimizing the care we are providing, the organization aims to ease transitions, establish therapeutic patient family centered care, improve documentation, and navigate cultural changes as Niagara Health prepares to build its new facility focused on care for the older person. Throughout my fellowship time I have been able to build capacity with various allied health members and make a presence throughout in-patient units across all sites. In the significant efforts to build capacity, allied health teams such as OT and educators have been even more collaborative in developing ways to sustain best practice to better care for our geriatric population. By incorporating the work of allied health teams and front-line staff, care plans are becoming more robust and thorough leading to patient specific care to better meet the needs of each patient. Through this fellowship I have grown more confident in my ability to educate and lead discussions about integration of BPGs into work and how as an organization we aim to continually improve practice. As a member of the Best Practice Spotlight Organization Committee, BPG work and the development of a champions network is an integral piece to the sustainability of this project. Throughout the final weeks of the fellowship collaborative efforts were made to meet with various interprofessionals such as OT, Geriatric CNS, and educators to provide education on new tools and strategies for improved assessments and care for our geriatric population for ongoing sustainability.
Outcomes
The data collected at the beginning of the fellowship indicated that staff were describing changes in behaviour within their narrative documentation but were unable to apply their clinical findings to the “Confusion Assessment Method” tool (CAM). Initial chart audits also noted poor use of Dementia Observation Screening (DOS) for older persons with behaviours and even those in physical restraints. There was noted to be minimal use of adjunct documentation tools such as DOS, This is Me, Short CAM and non-pharmacological strategies to delirium prevention and management, despite clear policy and procedures delineating standardization of best practices. Previously implemented tools such as Montessori Kits were under utilized throughout the COVID pandemic. The post COVID recovery plan portion of this fellowship looked to revitalize these investments and strategies. As the fellowship drew to an end, huddle talks to promote the newly created tools, Z-packs, and revitalization of Montessori sparked some thoughtful questions, and to build a sustainability plan with ongoing education/rounding throughout the year to align with dedicated calendar days (ex. World Delirium Day, Seniors Month, etc.), interest in champions work from the front line workers, and collaborative groups with touchpoints to continue to disseminate knowledge, and collaborate on patient care models for older persons. Increased CAM screening has been noted in patient units as well, there has been identified increase use of non-pharmacological strategies including Montessori across all sites with greater adherence to documentation and patient specific care plans.
In alignment with the Social Movement Action Framework principles, staff have remained very engaged and have had the opportunity to provide feedback to aid in the creation of new documentation and teaching tools. Huddle talks, rounding, and collaboration meetings throughout the duration of the ACPF have been effective in identifying a need for change, preparing and implementing change, and working to create a comprehensive sustainability plan. Staff across the organization have identified the need for improved documentation strategies and revitalization of current practice to ultimately help reduce work load and allow for the most optimal patient care experience. Stakeholders understand post COVID recovery is imperative and now that staffing is beginning to stabilize which is leading to better managed workloads, a refresh in culture is much needed. As Niagara Health navigates the development of the new South Niagara facility and the release of the new Strategic Plan, these changes are providing empowerment to staff to improve daily work, provide extraordinary care and work to decrease adverse patient experience while admitted to inpatient units across all sites in all levels of care.
Overall experience
Having the opportunity to complete an ACPF was a dream come true. As an individual who bridged from RPN to RN, I had been awaiting the opportunity to share my passion for best practice work with individuals who share my same values. By completing the ACPF I have grown more confident in my abilities to integrate BPGs into work and help staff correlate daily work into evidence supporting why this is important. Having been recognized by senior staff and colleagues for the work completed throughout the ACPF has inspired me to continue with a passion for teaching, education, and continuation of my personal and professional development.
