What was the issue you were addressing or working on?
The service aims to promote the understanding of the need for an integrated approach in care of the elderly in acute care. It demonstrates the impact that psychiatric morbidity can have on physical health and rehabilitation and how joint working with other professional groups can improve the quality of care and outcomes for elderly patients. It has developed and implemented an acute pathway for people with cognitive impairment entering the acute hospital, and assisted in early identification and diagnosis of dementia by providing specialist assessment and treatment interventions, education and support to patients, staff and carers.
What you did?
The appointment of a Consultant Psychiatrist with a special interest in Liaison Psychiatry for the elderly took place in Oct 2011, at which time there was 2.4 WTE liaison nurses. Initially the service was primarily a consultation-liaison service responding solely to referrals from acute wards. The development of an integrated care admission unit was a pivotal development and allowed much closer liaison between acute and psychiatric staff with the aim being to manage patients with high levels of co-morbidity, jointly, thus enhancing patient care and improving outcomes.
The number of elderly patients in the acute hospital accounts for almost two thirds of inpatients. The Dementia Strategy particularly focussed on care in Acute hospitals and estimates suggested around 100 patients in an average DGH at any one time would have dementia. The numbers actually identified were far short of this and indeed many referrals were of patients already known to the service.
Two additional liaison nurses were appointed through the Change Fund with the aim of providing a more proactive service. The service focussed on early identification of psychiatric morbidity, particularly at the ‘front door’, prompt assessment of cognition, identification and management of delirium, and engagement with carers. The service extended to seven days a week with daily input to AAU and the integrated admission units.
Bi annual training days for staff in the acute hospital were established; an acute care pathway developed and links with local community services developed.
Three monthly point prevalence studies have been carried out in the acute hospital. Audit of referrals, lengths of stay, discharge destinations and new diagnosis have all been undertaken. Work is currently underway to develop specific tools to measure patient and carer satisfaction.
What were the outcomes - benefits or otherwise?
We are highly visible in the acute hospital and have improved relationships with colleagues in acute who are more aware of psychiatric issues in elderly patients with acute ill health. There is better identification of delirium, dementia and depression and consequently improved management of these complex individuals. Referral rates have increased exponentially, but there is also an enhanced awareness of the impact appropriate psychiatric interventions can have on recovery and rehabilitation.
There is better communication with carers and the use of collateral histories. We have improved the management of people with dementia and identified around 98 new cases over the past six months who otherwise may have gone unrecognised. This has allowed appropriate feedback from trained staff to patients and carers, ensured that they are given education and information about the condition and that they have the right treatments and referrals made for ongoing support. The lengths of stay are less for patients involved with OALP service and fewer end up in institutional care.
The service has been highlighted in the recent OPAC report as an area of best practice. The challenge will be securing ongoing funding for the additional nursing posts as it would be unsustainable with fewer staff members.
As the population ages and admissions to acute care become increasingly complex, the ability to provide an integrated approach to care will become increasingly important. Around 15% increase in the numbers of people over 75 will occur in the next 5 years…..just a 10% rise in demand for hospital beds will make the current system unsustainable. Reduction in admissions, reduced lengths of stay and alternatives to IP care will all have to take place and the liaison team will have a major role to play in helping achieve this. So whilst we have made significant strides forward to date, there is still much to contribute.
Contacts - to find out more
Dr Gillian McLean, Gillian.firstname.lastname@example.org 01324673818