Posted by: ayrshirehealth | December 3, 2014

Flying without wings by @mclaughlynn

And now for something completely different 

Cremona (Italy)Flying without wings is of course an amazing song, sung by one of my favourite groups Westlife, and this is how I felt when I was given funding to attend the European Delirium Association (EDA) conference in Cremona, Italy in November this year.

The furthest I have been on study leave is Edinburgh so this was an amazing experience and opportunity for me – so this is how it all began.

Leading from the front

I am a Senior Charge Nurse in Older Adults Medicine within Crosshouse Hospital and also a Dementia Champion and very passionate about my role, my team and of course improving care for the patients whom we care for.

University Hospital CrosshouseSo for me the term Flying without Wings captures our Associate Nurse Director Angela O’Neill & Associate Nurse Director Derek Barron’s belief in me that I could be involved in changing how we deal with delirium and to improve the patient journey if you happen to be admitted or develop a delirium within one of our hospitals.

TIME

A few years ago I attended the launch of Health Improvement Scotland’s (HIS) work stream in Identifying Frailty and also Delirium.

Think delirium 2Think FrailtyDelirium is a medical emergency : a state of mental confusion.  It is also known as “acute confusional state” – illness, surgery and medications can all cause delirium.  It can start suddenly, but usually improves when the condition causing it improves – it is frightening – not only for the patient who is unwell but for those who care for them.

Along with our colleagues at HIS we asked to take part in the pilot of THINK DELIRIUM using the TIME Bundle which is a tool to enable staff to identify:

Time bundleT – think triggers e.g. sepsis , medication change, pain, constipation

I – Investigate e.g. hydration, chest , signs of infection

M – Management – initiate treatment

E – Engage and explore – ? is this a new behaviour change

Working alongside Dr Claire Copeland Geriatrician in Stroke and Dr Ajay Macharouthu Liaison Consultant elderly Mental Health we set up a Delirium group and have been working alongside HIS and Station 16 , Station 7 (University Hospital Ayr), 3E and 5D (University Hospital Crosshouse) to improve staff education and awareness of delirium .

What did I learn

So back to Milan and the European Delirium Conference – what could I take back to my area from attending this ?

It was refreshing and enlightening to hear that delirium is a worldwide issue and all the different countries Italy, America , Norway and even Ireland are all experiencing the same issues with identifying and treating and managing the symptoms .

Delirium 2It is clear that at NHS Ayrshire and Arran we have managed to start the ball rolling in terms of identifying delirium and having a treatment plan and guidance however it is only being tested in several wards

– we need to be able to share our experience and our treatment plan pathway with the rest of NHS Ayrshire and Arran, and I am sure that our colleagues at HIS and Clinical Improvement will help with this rollout.

Collaboration

The message was clear listening to all the different speakers at the EDA conference – staff education is key and what stands out for me is we must empower the nursing staff as they know the patients best in partnership with relatives and carers.

It’s going to be a huge challenge but the EDA conference showed me that we need collaboration and I have returned with enthusiasm, determination , new found friends in high places and of course the support of NHS Ayrshire and Arran to strive forward in the identification and treatment of delirium.

Yet another blog to be continued ……….  I promise I will.

This week’s blog was by @mclaughlynn (Lynn McLaughlin) Senior Charge Nurses, Ward 5D in University Hospital Crosshouse, NHS Ayrshire & Arran.

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Responses

  1. ” I have returned with enthusiasm, determination …” Great article Lynn. As an elderly patient (69) I applaud this excellent focus to my continuing healthcare.

    • Thank you Brian . We all try our very best to strive forward & improve our patients care . This can be very difficult due to such negative media coverage of older adults care . NHS Ayrshire & Arran are leading the way in older people’s care & it’s because we all really care that we continue to improve our service .
      Thanks again for your kind words x

  2. As a 62 year old woman I am concerned about the focus on delirium and frailty, linked to “mental confusion” which might lead to an incorrect early diagnosis of dementia. For I think that going into hospital for any treatment can be traumatic for patients young and old. Away from home and the familiar.

    I would rather it was Think Person-Centred. Treating each person as an individual human being, not seeing being old as a sign of weakness. There are so many benefits to being older. I can testify to this. There is life experience, the stories gathered over the years, the memories which give colour and depth to life. I’m not keen on these images in the blog, older people’s faces with words stamped on them. It can be seen as stigmatising or discriminatory. Old age = Frailty = Delirium.

    Since entering my 60’s I have become a prolific writer, activist and campaigner in mental health matters. Age has not slowed me down. I am an unpaid carer, supporting two sons who have mental health difficulties. I participate in many events as an “expert by experience”. My life is very full and interesting. I look upon old age as an opportunity to use my life skills, qualifications and experiences to their maximum. I wouldn’t like to think that because of my older age my words were somehow less valuable.

    I realise that this blog is geared towards nurses and hospital staff but for me as a potential patient it is offputting to hear how I might be viewed if confused after hospital procedures. At risk of labelling in the medical notes as frail or delirious or demented. That is indeed frightening. It would make me think twice about going in to hospital for treatment. Would I come out again as a person or as a diagnosis of dementia?

    Let’s not lose sight of the many benefits of old age and the elderly in our communities. We are a resource and the means by which stories are passed down the family, from generation to generation. Think Positively about us as People First, is my exhortation.

    • Lynn firstly I would like to say thank you for sharing your experience you are a true clinical leader. You are making such a difference to the experience of families, carers and to the people in our care.

      Chrys the gentleman you refer to with the stamp on his face is my Uncle a truly wonderful man with a heart full of kindness. When he had delirium I found him drowsy, lifeless, dehydrated, distressed, incontinent with hands covered in faeces. He had a plate of cold food in front of him and fluid firmly out of reach. He has dementia but unfortunately no one caring for him understood delirium. My uncle deserved to be cared for by knowledgeable staff, unfortunately he did not receive the type of care dedicated staff like the teams in A&A are providing. My family are honoured to help change experience for others because they understand the real harm to their loved one if delirium is not recognised.

      • Karen I am sorry to hear that your uncle has dementia and that he did not get appropriate care when he needed it. I know what that’s like, dehumanising treatment in hospital settings. My youngest son was locked in a seclusion room in a psychiatric ward, no toilet or water to drink, for hours on end. My complaint was recently upheld by the Ombudsman who declared it to be “unreasonable treatment”.

        However this doesn’t change my opinion about the images used. If I ever get dementia I don’t want my family to use my image in a blog post or anywhere without my permission, with anything stamped across it. I will be sure to let them know this when I am in my right mind.

        I think we have to be careful in social media that we are treating people as human beings and not as means by which we get our message across. What might be OK for one person might not be for another. Therefore it is good to listen to ALL the voices. Positive and critical feedback. If we all said everything was wonderful then there is the danger that things may not improve in health settings and that patients will be at risk. Of injury. Of disrespect. Of not being listened to. In my opinion.

  3. thanks for your response – I am sorry that you viewed my article in such a negative way – however I can assure you that Delirium is a medical emergency & the quicker it’s identified & the cause treated the better the outcome – mortality rate is high if cause not treated . If you think of it in the same way as an emergency like a heart attack or stroke then I hope you realise how valuable it would be for medical staff to diagnose & treat quickly.
    We are trying to improve the treatment of delirium it is a national & worldwide campaign – we are not alone in this .
    Dementia would not be diagnosed alone on the grounds of confusion – people need a patient centred comprehensive assessment before that would be done – Young or old can have delirium – it’s frightening for everyone involved so we need to improve .
    The think frailty & think delirium posters are part of health improvement Scotland’s campaign & it looks better on a poster than on my blog – we are raising awareness , we are not in anyway being negative or disrespectful & I am sorry that you took it that way .
    Our team has great enthusiasm , compassion & drive to improve older people’s care .

    • Lynn thanks for responding. Firstly I wanted to say that I viewed your post critically not negatively, there’s a difference. Critical feedback can be positive in terms of looking at a topic in a different way. Considering how it might appear to non-clinical readers. Helping to bring about improvement in terminology or presentation.

      I hear what you are saying about the images being usually on a poster however that wouldn’t make me think them more acceptable. And I’m entitled to express my opinion. I did so hoping that it might be considered a valid one.

      I didn’t say that you or your team were being “negative or disrespectful”. I spoke generally about the benefits of both positive and critical feedback helping to improve services so that people were listened to, respected and safe.

      I do believe that patients and carers should be involved in the process of improving the screening for delirium. And that might mean having to listen to critical feedback, stories about what hasn’t worked or could have worked better.

  4. Lynn, well done on an excellent blog. The importance of the work around delirium is so important. We know that approx 20% of people in hospital are likely to have a delirium. We also know from the evidence that it is associated with an increased mortality, you’re more likely to end up in a care home instead of the place you call home and we know it can be associated with developing a dementia. On top of all that we know how frightening and distressing it is for families to see their loved one suffer in this way. The person can also remember it too.

    Delirium can be treated and it can be reversed.

    What frightens me is that in knowing these facts that it can go undetected if the appropriate screening is not done. The right treatment is not started. The right follow up to ensure the person has recovered is not in place. That families and carers are left with no understanding of what has happened to their loved ones.

    I think having you lead the nursing staff to ensure this doesn’t happen is only to be applauded. That people are correctly diagnosed, get better and back to being the amazing person they have always been.

  5. This is been a helpful discussion. It is clear to me that all participants seek to improve care for our elders.

    Dr Copeland states “What frightens me is that in knowing these facts that it can go undetected if the appropriate screening is not done.”

    With screening we are talking about an approach that does not require consent. This I would argue we need to consider most carefully especially as screening with “screening tools” can have harmful as well as beneficial outcomes. This is why the World Health Organisation are very clear in providing a framework to guide us.

    It would be helpful if “detection” in Scotland, as part of improvement work, was acknowledged as what it is. That is screening using a “screening tool”. I think we could then discuss this openly and include our elders in what needs to be a wide-ranging discussion.

    My response to the new Draft Care Standards, covers some of these areas: http://wp.me/p3fTIB-C2

    I have also summarised my thoughts on Delirium Screening here: http://wp.me/p3fTIB-t0

    Thanks again for this blog-post.

    aye Peter Gordon

  6. Thank you Lynn for a great blog. It is so reassuring to know that staff have the knowledge and skills required to detect, manage and treat a potentially life threatening condition. As a close relative of a recent service user with a secondary diagnosis of delirium I have to commend the standard of care that was received. As a family unit we were treated with dignity, care, compassion and respect. Resulting in truely person centred care being delivered and an admission period of <24hr. As a service user, I thank you NHSaaa, keep up the good work Lynn.

  7. Lynn

    An excellent blog, thank you for your enthusiasm and commitment to lead your team in providing high quality, person centred care. I consider your blog and the work you are doing as focused on individuals and putting them at the centre of care. I know you put people and families at the centre of care, I know because I’ve seen it first hand, indeed it is one of the reasons Angela O’Neill and I were supportive of you going to the conference. Using a systematic approach to care does not mean it is less personcentred, nor does it mean everyone is considered as weak or having a negative label stamped upon them.

    So what is the great debate or points of contention?

    Is it the two questions and the two observations that make up the 4AT? To be honest these questions were (in various guises) what I was taught as a student nurse back in the 80s, so not that new and not that controversial. It must surely be the two observations therefore!

    [1] ALERTNESS​
    This includes patients who may be markedly drowsy (eg. difficult to rouse and/or obviously sleepy during assessment) or agitated/hyperactive… … ask the patient to state their name and address to assist rating.

    One would have thought assessing this as a rapid onset event would be a good thing, and within the ED might only be possible with input from relatives concerned by this sudden event! I would have thought therefore that this isn’t the issue of contention.

    [4] ACUTE CHANGE OR FLUCTUATING COURSE
    Evidence of significant change or fluctuation in: alertness, cognition, other mental function
    (eg. paranoia, hallucinations) arising over the last 2 weeks and still evident in last 24hrs

    Yet again, I would have thought something we’d want to know, and it was something I was taught as a student MH nurse as part of a comprehensive assessment.

    Again I’m struggling to understand what is alleged to be so drastically wrong.

    Will the use of 4AT lead to inappropriate diagnosis of dementia?

    No, the 4AT is not a tool to diagnose dementia – a ‘wrong’ diagnosis of dementia can only be made by a geriatrician or psychiatrist following additional clinical assessment. Might it lead to timely recognition and diagnosis of dementia for some people, yes, it might. Surely this is a good thing – unless of course the writers think that our Dementia Strategy and Alzheimer Scotland have got that wrong as well. Another alternative might be that people are calling into question the clinical expertise/competence of those making the diagnosis of dementia, which, given it is not you or your team begs the question of why comment here and not to the regulatory bodies (eg GMC)?

    Does it over medicalise the confusional state?

    No, delirium it is a medical issue requiring immediate intervention to a) save lives and/or b) understand the changes that occurred leading to the acute confusional state. Post acute phase alternative interventions, or indeed no interventions, would be part of an agreed plan of care.

    I wonder if it’s that the approach is advocated for everyone over 65yrs that is the contention?

    Indeed I may have some sympathy for that, bearing in mind 65yrs is a relatively arbitrary number, it could just as easily be 64 or 66yrs. That said, 65yrs is as appropriate as the other ‘number’ and unless compelling evidence is presented to revise the age range, it seems sensible to agree a systematic approach to assessment. As can be seen from the NICE guidelines attached, they also advocate 65yrs of age and above as a starting point of assessment – albeit we acknowledge that NICE wrote these guidelines to apply in England and Wales.

    NICE Guideline – https://www.nice.org.uk/guidance/cg103/resources/new-nice-guideline-set-to-encourage-healthcare-professionals-to-think-delirium-and-take-steps-to-prevent-it

    Adults admitted to hospital or to a residential care home or nursing home who are thought to be at risk of delirium are assessed to spot any recent changes in their behaviour that may show that they have delirium. A person is at risk of delirium if any of the following apply: they are 65 or older, already have difficulties with memory or understanding (known as cognitive impairment), have dementia, have a broken hip or are seriously ill.

    Dr Fergus Macbeth, Director of the Centre for Clinical Practice at NICE, said: “This new guideline will encourage doctors, nurses and care assistants in hospitals and long-term care settings to ‘think delirium’ and take steps to prevent this serious condition. It is vitally important, too, that those who care for people at risk of delirium are familiar with the indicators and symptoms that suggest the onset of this condition.

    “In implementing this guideline, healthcare professionals and those working in long-term care will be providing people with, and at risk, of delirium with the highest level of care.”

    Professor John Young, Honorary Consultant Geriatrician, Bradford Teaching Hospitals Foundation NHS Trust, Chair of the Guideline Development Group, said: “We know delirium is preventable, which is why the new guideline contains recommendations especially designed to ensure people at risk of delirium receive good quality care. Our recommendations put the individual first by emphasising the need for individual, tailored interventions which will vary for each different person.

    “Our guideline development group included a range of people, including health and long-term care professionals and patient representatives who are familiar with the serious effects delirium can have. We discussed all the best available evidence in developing this clinical guideline and I’m confident these recommendations are set to make a real difference to the diagnosis, prevention and management of delirium in England and Wales.”

    I was listening to this years Reith Lectures by Atul Gawande in which he noted a survey of surgeons who resisted using checklists pre surgery, despite clear and significant improvements in their mortality outcomes when they did. Yet when asked, 84% stated they wanted any surgical team operating on them or their family to use the checklist.

    4AT isn’t a checklist, it’s a systematic approach to assist clinicians to intervene timeously when required. If it was my family, or if it was me, I would want the clinical team to take a structured, systematic approach to their assessment and interventions – it might very well save my life, or one of my family.

    Thanks for your blog and your clear, unmistakable focus on those in your care.

    Derek

    • Derek thanks for your input.

      I hear what you are saying about 65 being “a relatively arbitrary number”. I agree that it’s only a number and that the key is to provide timely, appropriate and professional care and treatment to every person, regardless of age.

      You ask “what is the great debate or points of contention?”. For me as a non-clinical person commenting on this post but also an unpaid carer, an expert by experience in terms of being a patient, in general and mental health settings, it’s about voicing my opinions and concerns. And being heard.

      I’m a blogger and write on my own blog and on others, as a guest writer. On my own blogs I can moderate the comments before they go up, on other blogs I can’t, therefore I have to respond to critical (or negative as they have been described here) comments. I find that the critical points made on my blog posts cause me to reflect on my words, my thoughts and my practice. Because I am a reflective practitioner in other fields – of community learning and development, also FE teaching.

      Regarding the reasons for anyone commenting on this blog then that is up to them. I’m not a mind reader. The whole about blogging and commenting is to engage, critically or otherwise, as I see it. It may be to agree with some of what’s being said and to question other things. I’m a person of independent thought and there is nothing “wrong” with that. In my opinion.

      Why should differences of opinion be a threat to others? That’s the question I would pose to you and to others. There is nothing to fear from questioning or critical voices. In defending our position there is no need to attack another person’s position. Debates are about different views, sometimes opposing views. There is no “right” answer I contend however there is often a “better” way of doing things. That’s what I and “others” are working towards. Collectively.

    • Derek here is a response to some of the points you make in your comment, December 6, 2014, at 11:29:

      You mention “struggling to understand what is alleged to be so drastically wrong”

      (1) The risks of misdiagnosis and over-diagnosis of both delirium and dementia are very real by taking the screening approach which is mandated. Doctors tell me this is the case

      (2) They are screening without consent.

      I understand that NICE do not recommend screening for all, just those “at risk”. I am hearing that the NICE Guidelines, when searching the word “delirium”, never once use the word “screening” presumably because there is no evidence behind such an approach. It seems that HIS have decided (by themselves) that all our “elderly (those 65 and over) are ‘at risk.’

      You say that [this approach] is “not that new and not that controversial”. I am hearing that this is not the case. It is a new “screening tool”. Screening is a most controversial subject generally e.g. prostate screening, breast screening to name but a few.

      You say “Might it lead to timely recognition and diagnosis of dementia for some people, yes, it might. Surely this is a good thing – unless of course the writers think that our Dementia Strategy and Alzheimer Scotland have got that wrong as well.” Let’s remember that the “timely diagnosis” campaign was led by Dr Peter Gordon. Prior to this Scottish Government was promoting “early diagnosis”.

      I have heard experienced doctors say that you cannot diagnose somebody with dementia when they are experiencing delirium. Awareness of increased risk of dementia is appropriate.

      Finally you say that “4AT isn’t a checklist, it’s a systematic approach to assist clinicians to intervene timeously when required.”

      I would say, after consulting with clinical expert practitioners:

      (1) it is a “screening tool”. This is how 4AT has been registered and is being used

      (2) it may be a “systematic approach” to the whole population but it is NOT a “systematic approach” in the holistic assessment of the individual. I have heard doctors say they would use the 4AT, as for other rating scales, to support diagnosis of delirium following time-honoured nursing and medical assessment.

      I hope this is helpful to the discussion. Chrys


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