After more than 30 years working in NHS Scotland I took up my current post a little over two years ago. I was about to get my eyes opened. I also think I’ve turned into Mr Angry (or at least Mr Frustrated). By dint of being an NHS nurse, I or my service were used to being included in every event that went on - nursing development events, strategic visioning events, think tanks, quality improvement, learning and education improvement programmes, the list goes on.
When undertaking service improvements/quality improvement we wouldn’t have dreamed of starting these without the required participants being in the room. A&E, we’d have the A&E team in the room… mental health safety programme - we’d have, at the very least, representatives from each discipline, from wards and community teams, managers and clinicians.
And now? You’d be surprised how many ‘integration’ events go on without the care home sector being invited or involved; and how many care home improvement initiatives are proposed without care homes being included, or asked to be involved.
Did you know that there are more care home beds for older adults (37k) in Scotland than there are hospital beds in NHS Scotland (12k)?
A few weeks ago, at an NHS-generated meeting, we were told that 35% of care home residents who were taken to A&E weren’t admitted - we were told “that’s clearly an area where we need to focus education on how to prevent attendances”!! For clarity, that was the totality of the statistics presented, no drilling down into the clinical presentations, just that we (in care homes) were doing something wrong. “We” also need to do some work on the number of falls in care homes! Really?
As a starting point for this declared need for us to improve, here are some statistics for consideration:
Every resident who moves into an Erskine Care Home has their mobility assessed by our in-house physiotherapists within 24 hours of moving in. They then have an agreed, shared activity programme planned.
We can track every fall over the past two years that led to injury and look at factors that are causative and those that are preventative.
But I guess if people never ask what we do, they might decide we have a problem that they, the NHS, can fix it for us – after all, no-one falls in hospitals so clearly they have the expertise to share.
The purpose of this blog isn’t just to moan, that’s not my preferred styled. I hope to open up a world, that to some is an unknown world that they are happy to try to ‘improve’.
So now for something completely different.
Delirium is an interesting and under researched topic in the care home setting. Research by Siddiqi et al has suggested that the prevalence of delirium may be as high as 28% in residents living with dementia. This could range from 18 - 28%, which if accurate means we have a significant life-limiting, but treatable, situation across the care sector (acute hospitals are only mildly better).
So what to do?
In two of our care homes we used to write a paper referral when requesting a GP visit. Despite training on delirium from our Dementia Nurse Consultant we also recognised that staff (registered nurses and senior care assistants) were not always completing a 4AT before referring to the GP. However it does seem that staff recognise signs and symptoms of delirium while not always using the term ‘delirium’.
This initial audit was followed up with the use of the 4AT being mandated for use from March to May 2019. At the time of presenting this data to the BGS spring meeting we will have one month of data to share - at the time of writing this blog I’ve no idea what it will say, so hopefully you’ll be at the meeting and can share your insight into what the data means.
Care Homes are a career backwater! Heard that said? Perhaps you’ve said it yourself?
In terms of career there are few places where someone can start as a modern apprentice and end up as the Director of Care. At Erskine we have a nursing team career ladder that stretches from (pre-nursing) modern apprentices in care into registered nurse posts (of which there are nine different roles) all of which operate in a dynamic person-centred environment where our residents are at the centre of our day, not ‘flow’ through a hospital.
Teaching, research, quality improvement, clinical and care governance are all embedded in our services. Electronic care plans, electronic medicines management systems (that talk to each other) are day to day solutions for us.
So next time someone has a great idea of how to improve care delivery within a care home or has a way to help us improve the interface between care homes and Acute services, why not ask us before you decide what’s needed. You might find we are eager to be part of change, of innovation and improvement and we might have some ideas of our own, we simply need listened to and respected for our ideas.