1. TOP 5
TOP 5 – Promoting Person-Centred Care, for Hospital Patients living with Dementia, through Carer and Staff Dialogue .
AUTHORED BY: Dr. Sian Keane; Mette Stanbury; and Maureen Strudwick, Carer Support, Central Coast Sector, Northern Sydney Central Coast Area Health Service
Results
Results
Top 5 in action:
“Around 4pm everyday Fred would put the car in the garage. He hasn’t driven for 12 years, but he still looks for his car keys around 4 pm. He can become a bit cross.. Tell him the car is in the garage, and he will settle down.”
“Make sure his notebook is visible at all times..”
“When he fidgets with his buttons he wants to go to the toilet.”
“He likes to sit looking out the window at the trees.”
“Mum is not incontinent, but does need someone to take her to the toilet. At home, my brother sets the alarm for 1am to take mum to the toilet - she has never wet the bed. If a nurse took her to the toilet regularly, and woke her up at night, she wouldn’t be incontinent. It would be more dignified for mum, and would save the work cleaning up.”
Top 5 Algorithm
Over the last 12 months Top 5 has been rolled out in 18 wards across three hospital campuses. The CPI model has informed the development of many Top 5 resources to address the unique needs of each setting. The algorithm is an example of one such resource.
This Algorithm identifies the process whereby the Top 5 essentials are addressed:
Primary Carer must be identified
Carer is acknowledged as having expert knowledge of the patient
Top 5 strategies are discussed and negotiated
Top 5 strategies are written down and placed to ensure they are readily accessible to ALL staff
Background
In 2007 a working party for acute hospital care chose to address issues of identification, assessment, and management of patients with confusion. The working party identified a need for a paradigmatic shift from a focus on management of challenging behaviours to an understanding of what is being communicated by the behaviour. An innovative person-centred approach to support inpatients with confusion was required.
Carers attending Dementia Carer Support groups reported when they approached hospital staff to provide information, and suggestions for personalised care staff did not record the information or pass it on in a meaningful way. Carers were frustrated at repeating themselves, and constantly worried that when they were not in attendance, the patient would be unsettled and non-compliant with medical treatment.
The Carer Support Unit, Central Coast, undertook a literature review on cognitive impairment and behaviour. Much of the literature suggested that challenging behaviour was a form of communication. Family were identified as holding the key to understanding that behaviour.
Aims
To develop a protocol for clinical staff, to engage carers of cognitively impaired patients.
To gain carer input into developing and recording ward based strategies to improve communication, care for, and management of, cognitively impaired patients.
To ensure strategies will be easily recognized by, and accessible to, all clinical staff.
Method
The Clinical Practice Improvement (CPI) Model - a ‘trial and learning’ approach to improvement - was chosen as the model to guide the project.
Pilot study of 8 weeks was implemented on two medical and two surgical wards from Gosford and Wyong Hospitals
The carer of a patient identified as having a cognitive impairment was approached either by phone or in person on the ward. Verbal instructions and a brochure were provided.
Carer invited to list up to five strategies that would promote communication and personalised care for that patient.
Strategies negotiated to ensure implementation was realistic for staff. They were then documented and placed at the front of the patient’s bed chart for all staff to access.
A small tag with Top 5 symbol was placed on patient’s name board above the bed, identifying patient as participating in the project.
Staff were given a one-off education session on project objectives, staff role, and Top 5 tools, and were given a resource folder.
Pre and post questionnaires, which were given to staff and carers of inpatients with cognitive impairment, were analysed.
Carers’ experience of interaction with staff
Pre Top 5
Post Top 5
Staff experience of interaction with patients who are cognitively impaired, and their carers
Conclusions
Patient Outcomes:
Less distress, frustration, agitation
Increased compliance with treatment
Better care and more effective treatment
More peaceful ward environment
Quicker recovery, earlier discharge
Carer Outcomes:
Carers more confident in, and comfortable with, the health care provided
Carers confident their care recipient will be more settled and comfortable when they are not at the bedside
Carers report feeling respected and valued with regard to their patient knowledge
Staff Outcomes:
Safer work environment
Better time management
Better discharge planning
Greater satisfaction
Less complaints from family & carer
References
Keane S. “Top 5 – Engaging Carers in Person Centred Care for People with Confusion and / or Communication Difficulties.” Paper presented at the ‘Getting on with Life – Rehabilitation and Chronic Illness in Old Age’ Conference, AAG, Wollongong, April 2008.
Keady, J & Nolan, M. (1994). The carer-led assessment process (CLASP): a framework for the assessment of need in dementia caregivers. Journal of Clinical Nursing 3,
Carer Support, Central Coast, 21 Beane Street, Gosford