A team from Lithgow Hospital has developed an innovative tool to improve the communication of unmet needs for hospital inpatients living with dementia, with an initial trial successful in improving patient outcomes.
People living with dementia are at an increased risk of hospital acquired conditions, including fall-related fractures and intracranial injuries.1,2 As their ability to communicate reduces, nonverbal communication is often a primary way they express their needs. Nonverbal behaviours such as agitation and restlessness are often outward expressions of unmet needs.2,3,4 When patients experience an increase in distress and restlessness, they are more likely to experience falls and to trigger code black calls (personal threat to staff, patients, visitors or others).
While person-centred care is recommended as best practice in addressing the unmet needs of older people living with dementia, there is a lack of understanding about the value and implementation of non-pharmacological interventions in busy acute settings. Effective patient care for people with cognitive impairment in the hospital setting relies upon the ability of both clinical and non-clinical staff to engage with them effectively.5 Robust communication among hospital staff, the person living with dementia and their care partners can increase the chances of a positive hospital experience.6
Improving health outcomes for inpatients experiencing cognitive impairment
The Tree of Life is an innovative and user-friendly communication aid designed to assist in the communication needs of people living with dementia who are in hospital. A 'personal passport' for people with dementia is a document that captures important personal and social information to support person-centered care. While there is evidence that personal passports such as Top 5, This is Me and The Sunflower are effective communication tools to address unmet needs, uptake in the acute setting has been inadequate both in Australia and globally.7,8,9
As staff working within the occupational therapy department at Lithgow Hospital, we created the Tree of Life to improve the communication of unmet needs by older people experiencing cognitive impairment during their inpatient stay.
The Tree of Life is a one-page image of a tree that sits on the wall at the head of the bed with a smaller version attached (question/answer style) to the foot of the bed. Both the image and questionnaire are filled out by either the patient's carer or an allied health assistant. The Tree of Life is completed during the first 24 hours of admission. It can be transported with the patient to another department, providing hospital staff with an efficient way to get to know the person, their likes, comforts and triggers. By increasing comfort and reducing distress experienced in the hospital environment, the Tree of Life aims to improve health outcomes for a person experiencing cognitive impairment in hospital.
An iterative approach based on patient and staff feedback
The Tree of Life has undergone several iterations based on feedback from patients, family, staff and evidence sourced from literature. It was trialled with 37 patients at the Lithgow Hospital inpatient unit (general medical and close observation ward) for nine months, from February to October 2024.
We used multiple data sources to evaluate the Tree of Life, including:
- incidents of falls and aggression recorded in the Incident Management System and Electronic Medical Record (eMR)
- data on falls with serious injury (resulting in fracture or other intracranial injury) obtained from Quality Improvement Data System
- code black calls via Lithgow Hospital switchboard
- care-partner and family survey created on the Quality Audit Reporting System (QARS)
- staff survey created on QARS.
Data collected included:
- code black calls
- number of fall incidents
- number of falls with serious injury (resulting in fracture or other intracranial injury)
- number of falls for inpatients who directly received the intervention
- examining medical record reports (coding)
- staff and care-partner feedback/views.
76% of participants had no falls when the aid was in use
The Tree of Life aid has led to an increase in person-centred care, and reduced the risk of falls, harm from falls, agitation and code black calls. From January to October 2024*, 810 patients aged over 65 were admitted to the Lithgow Hospital inpatient unit. Among that group:
- Cognitive impairment was present in 108 (13%) and we trailed the Tree of Life with 37 (4.6%) of them.
- The cognitively impaired group accounted for 75% of all inpatient falls. But none of the falls at harm score 1 or 2 level were experienced by the 37 Tree of Life participants.
- Of the 37 Tree of Life participants, 76% had no falls when the communication tool was being used.
- It is not entirely clear how the tool lowered the risk of falls, but we believe reducing agitation and distress is an important factor. An agitated person is more likely to try to stand up and physically move away from what is distressing them, for example trying to leave their hospital room, which could lead to a fall.
- In a survey about the tool, 90% of staff and 100% of family members rated it as ‘very good’ to ‘excellent’ as part of delivering person-centred care.
Code black calls in April, June, August, September and October 2024 also reduced to zero^. Most code-black calls in this age group are due to escalating agitation.
These outcomes indicate Tree of Life is an aid that provides crucial information about the person staff are caring for. It is easy for staff to use and helps them connect quickly and meaningfully with patients. It also helps clinicians create personalised strategies that reduce agitation and the danger it poses to patients.
*The Tree of Life was trialled from February to October 2024.
^Compared to a mean of 42% cognitive impairment-related code black calls from January 2022 to October 2024.
References
- Australian Institute of Health and Welfare. (2024). Dementia in Australia. Canberra: AIHW. https://www.aihw.gov.au/reports/dementia/dementia-inaus/contents/about
- Zonsius, M. C., Cothran, F. A., & Miller, J. M. (2020). CE: Acute care for patients with dementia. The American Journal of Nursing, 120(4), 34–42. https://doi.org/10.1097/01.NAJ.0000660024.45260.1a
- Zembrzuski, C. (2019). Communication difficulties: Assessment and interventions in hospitalized older adults with dementia. Try This: Best Practices in Nursing Care to Older Adults with Dementia, D7, 1–2. https://search-ebscohost-com.ezproxy.uow.edu.au/login.aspx?direct=true&db=rzh&AN=137059041&site=ehost-live&scope=site.
- Scerri, A., Scerri, C., & Innes, A. (2020). The perceived and observed needs of patients with dementia admitted to acute medical wards. Dementia, 19(6), 1997–2017. https://doi.org/10.1177/1471301218814383
- Murray, M. E., Wong Shee, A., West, E., Morvell, M., Theobald, M., Versace, V., & Yates, M. (2019). Impact of the Dementia Care in Hospitals Program on acute hospital staff satisfaction. BMC Health Services Research, 19(1), 680–680. https://doi.org/10.1186/s12913-019-4489-z
- Prato, L., Lindley, L., Boyles, M., Robinson, L., & Abley, C. (2019). Empowerment, environment and person-centred care: A qualitative study exploring the hospital experience for adults with cognitive impairment. Dementia (London, England), 18(7–8), 2710–2730. https://doi.org/10.1177/1471301218755878
- Clark, E., Wood, F., & Wood, S. (2022). Barriers and facilitators to the use of personal information documents in health and social care settings for people living with dementia: A thematic synthesis and mapping to the COM‐B framework. Health Expectations, 25(4), 1215–1231. https://doi.org/10.1111/hex.13497
- Grealish, L., Todd, J.-A., Teodorczuk, A., Krug, M., Simpson, T., Jenkinson, K., Soltau, D., & Stockwell-Smith, G. (2021). Feasibility of a two-part person-centred care initiative for people living with dementia in acute hospitals: A mixed methods study. International Journal of Nursing Studies Advances, 3, 100040–100040. https://doi.org/10.1016/j.ijnsa.2021.100040
- Royal College of Psychiatrists, (2019). National Audit of Dementia care in general hospitals 2018–19: Round four audit report. London: Royal College of Psychiatrists. https://www.rcpsych.ac.uk/docs/default-source/improving-care/ccqi/national-clinical-audits/national-audit-of-dementia/r4-resources/reports---core-audit/national-audit-of-dementia-round-4-report-online.pdf
