Please Let Me Out: a standardised capacity testing process for confused patient
4 July 2016 Last updated:
19 July 2016
Please Let Me Out: a standardised capacity testing process for confused patients
This project developed a standardised capacity testing and guardianship application process for confused patients, with a multidisciplinary approach to support decision making in the hospital environment.
To improve the compliance and quality of capacity assessments for confused hospital inpatients at Coffs Harbour Health Campus (CHHC).
- Provides a standardised, objective and multidisciplinary approach to capacity assessments.
- Improves the quality of care and health outcomes of patients with diminished capacity.
- Reduces length of stay (LoS) and provides a timely hospital discharge for confused patients.
- Improves medical documentation for confused patients.
- Reduces unnecessary guardianship applications to the NSW Civil and Administrative Tribunal.
- Improves clinicians’ knowledge, skill and confidence in dealing with capacity assessments and guardianship application processes.
Capacity is one of the foundation elements of human rights and determined by the cognitive ability to understand and appreciate contexts and decisions. When a person has the capacity to make a decision, they can:
- understand the facts involved
- understand the main choices available
- weigh up the consequences of each choice
- understand how the consequences affect them
- communicate their decision.
Capacity is not determined by whether they can perform certain tasks or daily activities, the choices they make and the outcomes of those choices, or if they disagree with the advice of health professionals.
Regional and rural hospitals are often faced with the challenge of deciding whether a confused patient has the capacity to make decisions about their healthcare and independent living, or whether they have lost the capacity to make these choices for themselves. These patients, who are often over 65 and have dementia, are contributing to an increasing number of hospital admissions in Mid North Coast Local Health District (MNCLHD). This trend is expected to continue, with research showing that by 2031, one in five people in NSW will be aged 65 and over. Dementia is the single leading cause of disability in Australians aged 65 years and over and the second leading cause of death in Australia.
Capacity testing for confused patients can be a challenging process and is often poorly undertaken in the hospital environment. Prior to the project, there was no standardised process for assessing whether these patients had the capacity to make independent medical, living or financial decisions. This led to vulnerable patients being hospitalised longer than necessary, as they awaited capacity assessments. There were also an unnecessary number of guardianship hearings, due to the poor quality of assessments and the reluctance of clinicians to complete the assessment in the first place.
An audit was conducted between June and August 2012, with 10 medical records of patients who were admitted to a medical ward during this time and whose capacity was in question. It highlighted the following results:
- 90% of patients were over the age of 70
- 70% had a history of dementia or cognitive impairment
- clinicians for these patients had minimal or no understanding of legal terms used in the assessment process
- 10% had a LoS of less than 10 days, 40% had a LoS of 10-20 days and 40% had a LoS over 20 days
- all audited patients had poor medical record documentation
- clinicians for these patients had a lack of objectivity and clarity about the capacity assessment process.
It was determined that a standardised capacity testing process for confused patients would reduce LoS, improve medical documentation, reduce unnecessary capacity assessments and guardianship applications, and improve the care provided by health professionals.
- A multidisciplinary team was formed to conduct a literature review, consult with hospitals in NSW, review legislation and audit medical records.
- A capacity assessment flowchart was developed for clinicians, to guide the capacity assessment and guardianship application process.
- Documentation guidelines were developed to record the assessment process and provide an explanation for the final decision.
- A capacity screening checklist was developed, to standardise the assessment and ensure all relevant factors are assessed objectively.
- Clinicians were educated on the new capacity assessment and guardianship application process. Two workshops were conducted for junior medical officers (30 participants), four for allied health staff (37 participants) and one for nursing staff (13 participants).
- The general practitioners of confused patients were contacted, to better understand their baseline cognition. This practice was recommended for all capacity assessments or guardianship applications.
- The procedure was formalised and introduced to all hospitals in the Coffs Clinical Network.
- Implementation - the initiative is currently being implemented.
- Project development: June 2011 – May 2015
- Local implementation: May 2015
- Coffs Harbour Health Campus
- Coffs Clinical Network
- Cartwright Consulting Australia
- An audit was conducted between May and July 2015, with eight medical records of patients who were admitted to a medical ward during this time and whose capacity was in question. It showed:
- a 90% increase in multidisciplinary team meetings
- a 65% increase in collaboration with general practitioners
- an 88% improvement in documentation of capacity testing.
- A staff survey of 47 clinicians conducted in seven education workshops showed that:
- 95% of participants found the training relevant
- 92% of participants found the training increased their knowledge, skills and confidence in dealing with capacity assessments
- 97% of participants were satisfied with the expectations of the training.
*Post audit length of stay (≥30) was increased by 17.5%, as three patients were awaiting NCAT-Guardianship hearing over 30 days in the hospital.
- MNCLHD 2016 Quality Awards Finalist: Local Solutions
- Never proceed with a capacity assessment and guardianship application, until patients are medically cleared of any irreversible causes or infections.
- Implementation was the most challenging element of the process. The support of senior management was a critical factor in the implementation and success of the project.
- There is potential for wider application of this process in hospitals, particularly in rural health facilities without access to geriatricians or psycho-geriatricians.
- Darzins P, Molloy W, Strang D. Who can decide? The six step capacity assessment process. Adelaide: Memory Australia Press; 2000.
- Diversity Services Unit, NSW Attorney General’s Department. Capacity Toolkit. NSW Attorney General’s Department; 2008.
- Mid North Coast Local Health District. Clinical Services Plan 2013-2017. NSW Health; 2013.
- Moye J, Marson DC. Assessment of decision-making capacity in older adults: An emerging area of practice and research. The Journals of Gerontology Series B: Psychological Sciences and Social Sciences 2007; 62(1): 3-11.
- Mullaly E, Kinsella G, Berberovic N et al. Assessment of decision-making capacity: Exploration of common practices among neuropsychologists. Australian Psychologist 2007; 42(3): 178-186.
- NSW Guardianship Tribunal. Guardianship Tribunal Annual Report 2012/2013. NSW Civil and Administrative Tribunal; 2013.
- NSW Department of Family and Community Services. Population ageing trends in NSW. NSW Government; 2014.
- Parliament of the United Kingdom. Mental Capacity Act 2005 (c. 9). United Kingdom: The Stationery Office Limited; 2005.
- Pinsker DM, Pachana NA, Wilson J et al. Financial Capacity in Older Adults: A Review of Clinical Assessment Approaches and Considerations. Clinical Gerontologist 2010; 33(4): 332-346.Purser K.J, Rosenfield
- T. Evaluation of legal capacity by doctors and lawyers: the need for collaborative assessment. Medical Journal of Australia 2014; 201 (8): 483-485.
Coffs Harbour Health Campus
Mid North Coast Local Health District
Phone: 02 6656 5136
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