Factors associated with shorter length of admission among people with dementia in England and Wales: retrospective cohort study.

OBJECTIVES: To identify aspects of the organisation and delivery of acute inpatient services for people with dementia that are associated with shorter length of hospital stay. DESIGN AND SETTING: Retrospective cohort study of patients admitted to 200 general hospitals in England and Wales. PARTICIPANTS: 10 106 people with dementia who took part in the third round of National Audit of Dementia. MAIN OUTCOME MEASURE: Length of admission to hospital. RESULTS: The median length of stay was 12 days (IQR=6-23 days). People with dementia spent less time in hospital when discharge planning was initiated within 24 hours of admission (estimated effect -0.24, 95% CI: -0.29 to -0.18, p<0.001). People from ethnic minorities had shorter length of stay (difference -0.066, 95% CI: -0.13 to -0.002, p=0.043). Patients with documented evidence of discussions having taken place between their carers and medical staff spent longer in hospital (difference 0.26, 95% CI: 0.21 to 0.32, p<0.001). These associations held true in a subsample of 669 patients admitted with hip fracture and data from 74 hospitals with above average carer-rated quality of care. CONCLUSIONS: The way that services for inpatients with dementia are delivered can influence how long they spend in hospital. Initiating discharge planning within the first 24 hours of admission may help reduce the amount of time that people with dementia spend in hospital.

Delirium screening and mortality in patients with dementia admitted to acute hospitals.

Objectives: Delirium is associated with increased mortality in older adults. National guidance recommends that all people with dementia who are admitted to hospital are screened for delirium. However, the impact of screening for delirium among inpatients with dementia has not been examined. This study aims to examine this relationship.Methods: Secondary analysis of data from 10,047 patients admitted to 199 hospitals in England and Wales that took part in the third round of the National Audit of Dementia. Multilevel logistic regression was used to examine associations between delirium screening and cognitive testing with inpatient mortality, adjusted for age, gender, diagnosis and hospital site as potential confounders.Results: The mean age of study patients was 84 years (SD = 7.9), 40.1% were male and 82.1% white British. 1285 patients (12.8%) died during their admission to hospital. Overall, 4466 (44.5%) patients were screened for delirium, of whom 2603 (58.6%) screened positive. The odds of mortality were lower in patients who underwent delirium screening (OR 0.84, 95% confidence interval 0.73 to 0.96) and in those receiving cognitive testing (OR 0.74, 95%CI 0.63-0.76).Conclusion: These results suggest that, among people with dementia who are admitted to hospital, screening for delirium and assessment of cognitive functioning may be associated with lower mortality. While we cannot be certain that these associations are causal, the findings support efforts that are being made to increase levels of screening for delirium among people with dementia who are admitted to hospital.

Older adult experience of care and staffing on hospital and community wards: a cross-sectional study.

BACKGROUND: Recent major concerns about the quality of healthcare delivered to older adults have been linked to inadequate staffing and a lack of patient-centred care. Patient experience is a key component of quality care - yet there has been little research on whether and how staffing levels and staffing types affect satisfaction amongst older adult hospital inpatients. This study aimed to evaluate the association between registered nurse and healthcare assistant staffing levels and satisfaction with care amongst older adult hospital inpatients, and to test whether any positive effect of higher staffing levels is mediated by staff feeling they have more time to care for patients. METHODS: Survey data from 4928 inpatients aged 65 years and older and 2237 medical and nursing staff from 123 acute and community medical wards in England, United Kingdom (UK) was collected through the Royal College of Psychiatrist's Elder Care Quality Mark. The cross-sectional association between staffing ratios and older adult patient satisfaction, and mediation by staff perceived time to care, was evaluated using multi-level modelling, adjusted for ward type and with a random effect for ward identity. RESULTS: Higher numbers of patients per healthcare assistant were associated with poorer patient satisfaction (adjusted ß = - 0.32, 95% CI - 0.55 to 0.10, p < 0.01), and this was found to be partially mediated by all ward staff reporting less time to care for patients (adjusted ß = - 0.10, bias-corrected 95% CI - 1.16 to - 0.02). By contrast, in both unadjusted and adjusted models, the number of patients per registered nurse was not associated with patient satisfaction. CONCLUSIONS: Older adult hospital patients may particularly value the type of care provided by healthcare assistants, such as basic personal care and supportive communication. Additionally, higher availability of healthcare assistants may contribute to all ward staff feeling more able to spend time with patients. However, high availability of registered nurses has been shown in other research to be vital for ensuring quality and safety of patient care. Future research should seek to identify the ideal balance of registered nurses and healthcare assistants for optimising a range of outcomes amongst older adult patients.

Recognition and treatment of depression in older adults admitted to acute hospitals in England.

Levels of awareness and treatment of depression in older adults admitted to acute hospitals are unclear. This study aims to examine the proportion of older adults diagnosed with depression in acute hospitals, treatment, referral, and communication between secondary and primary healthcare services following discharge. Retrospective examination of records of 766 older adults admitted to 27 acute hospitals in England was carried out. Ninety-eight (12.7%, 95% confidence interval (CI) = 10.6-15.3) records included a diagnosis of depression of which eight (1.0%, 95% CI = 0.5-2.0) had a new diagnosis made during their hospital admission. All newly diagnosed and 76 (84.4%, 95% CI = 75.5-90.5) of those with an existing diagnosis of depression were prescribed antidepressant medication. Six (75.0%, 95% CI = 40.9-92.8) of those with a new diagnosis, and 21 (23.3%, 95% CI = 15.8-33.0) with an existing diagnosis of depression were referred to liaison psychiatry. References to mental health were made in 50 (51.0%, 95% CI = 41.2-60.6) discharge letters sent to primary care. Very few older adults admitted to acute hospitals in this study were diagnosed with depression during their inpatient stay. Opportunities for improving the mental and physical health of such patients appear to be being missed.

Improving patients' and staff's experiences of acute care.

The aim of this audit was to assess the effect of the Quality Mark programme on the quality of acute care received by older patients by comparing the experiences of staff and older adults before and after the programme. Data from 31 wards in 12 acute hospitals were collected over two stages. Patients and staff completed questionnaires on the perceived quality of care on the ward. Patients rated improved experiences of nutrition, staff availability and dignity. Staff received an increase in training and reported better access to support, increased time and skill to deliver care and improved morale, leadership and teamwork. Problems remained with ward comfort and mealtimes. Overall, results indicated an improvement in ratings of care quality in most domains during Quality Mark data collection. Further audits need to explore ways of improving ward comfort and mealtime experience.

Quality of care for people with dementia in general hospitals: national cross-sectional audit of patient assessment.

There have been recent reports of poor quality care in the National Health Service in the UK, and older people with dementia are particularly vulnerable. This study aims to examine the quality of assessment of people with dementia admitted to hospital. Cross-sectional case-note audit of key physical and psychosocial assessments was carried out in 7,934 people with dementia who were discharged from 206 general hospitals. Most people had no record of a standardised assessment of their cognitive state (56.8%, 95% confidence interval [CI] = 55.8-58.0) or functioning (74.2%, 95% CI = 73.2-75.1). Information from carers was documented in 39.0% of cases (95% CI = 37.9-40.1). There was considerable variation across hospital sites. Key assessments were less likely when people were admitted to surgical wards. Assessments fall well below recommended standards especially with regard to social and cognitive functioning. Problems are particularly marked on surgical wards.

Factors affecting care on acute hospital wards.

AIM: To identify positive and negative aspects of the quality of care for older adults admitted to acute hospital wards during the Quality Mark pilot study. METHOD: A total of 306 patients and carers and 157 ward staff from 12 wards in six hospitals participated in a pilot study by completing questionnaires about the quality of care on the ward. They stated how much they agreed with a number of statements about care and provided additional free text responses. RESULTS: Patients rated staff attitudes highly, while staff expressed confidence in their skills in providing care. Patients rated the quality of food and the availability of staff lowest. Thematic analysis identified concerns about the ward environment, staffing levels and nutrition. CONCLUSION: Attention needs to focus on improving inpatient environments, nutrition and staff availability.

Adequacy of training in dementia care for acute hospital staff.

People with dementia are frequently admitted to general wards where their dementia is often unrecognised and related healthcare needs are unaddressed. This article examines how staff view the training they have received in assessing and caring for people with dementia who are admitted to hospital. It reports on the results of the National Audit of Dementia (Care in General Hospitals); staff completed questionnaires reporting the sufficiency of their training in 13 main areas related to dementia care. Responses were obtained from 270 doctors, 968 qualified nurses and 541 healthcare assistants (HCAs); 690 worked on medical wards, 677 on surgical/orthopaedic wards and 412 on care of older people wards. Doctors felt more adequately trained than nurses or HCAs. Nurses on medical and surgical/orthopaedic wards thought their training was less sufficient than their colleagues working on care of older people wards. The authors conclude that nurses and HCAs working on wards not specialising in the care of older people should receive increased training in dementia care.

Use of continuation and maintenance electroconvulsive therapy: UK national trends.

BACKGROUND: Continuation and maintenance electroconvulsive therapy (ECT) have been used for prophylactic treatment of recurrent depression but are poorly researched and not recommended by the National Institute of Health and Clinical Excellence, UK. AIMS: To document the demographic, clinical, and legal characteristics of patients receiving continuation or maintenance ECT, trends in their use, and whether the 2 types could be distinguished by duration and frequency of application. METHOD: Electroconvulsive therapy specialist psychiatrists completed postal questionnaires about its current use and retrospective use over the past decade. RESULTS: Thirty-five (34%) clinics responded, with 26% currently treating patients with either treatment. Its use has declined over a 5-year period after restrictive guidance by the National Institute for Clinic Excellence. The mean age of patients was 60 years, and more women are treated. Maintenance ECT was given for a longer duration and less frequently than continuation ECT. CONCLUSIONS: Use has declined since 2001-2002. Continuation and maintenance ECT can be differentiated according to the frequency and duration of treatment.