Dementia Care

47 / 68

Vol 5 No 5 October/November 2016 Australian Journal of Dementia Care 47
increasing prevalence and acknowledged
vulnerability of this population.
Preventable complications
My PhD focused on preventable
complications for people with dementia in
hospital. In collaboration with the
NHMRC-funded Hospital Dementia
Services Project and theAustralian
Institute of Health andWelfare, I looked at
data collected by NSWpublic hospitals in
2006 and 2007 and analysed nurse sensitive
outcomes for people aged over 50.
My study found that patients with
dementia have higher rates of hospital-
acquired complications than those without
dementia at the same age. The highest
rates were for urinary tract infections
(UTIs), pneumonia, pressure areas and
delirium, where the risk is 2.5 times
greater (21.9% of patients with dementia
experienced an in-hospital complication,
while only 8.8%without dementia did)
(Bail et al 2013).
These four key complications resulted in
the patient with dementia spending eight
times longer in hospital than a patient
without dementia (3.6 days compared to
0.4 days), doubled the average cost of stay
($16,403 compared to $8240) and
accounted for 24.7% of the cost of
additional days spent in NSWhospitals in
2006-2007, at a cost of $225 million per
year. Patients with dementia accounted for
22% of these costs, even though they
comprised only 10.4% of the hospital
population (Bailet al 2015).
These four complications occur more
often in older patients with dementia and
the high rate makes them expensive – yet
they are potentially preventable. However
the care needed to prevent them – such as
mobility, hydration, nutrition and
communication – is known to be rationed
or left unfinished by nurses (Papastavrou
et al 2014). Older patients with complex
health issues are more likely to experience
care rationing, as their care tends to take
longer, be less predictable and less curative
in nature (Bail & Grealish 2016).
The presence of UTIs, pneumonia,
pressure areas and delirium can be
considered as a hospital’s ‘Failure to
Maintain’ older people with complex
needs such as dementia in hospital, and
hence may be useful indicators for hospital
quality.
Quality nursing care
Promoting healthy nursing work
environments that minimise nurses’
rationing of functional and cognitive care
for patients is likely to reduce these
complications and associated costs.
Other research shows the association
between nursing staff levels and rates of
complications. For example:
• Less burnout and higher nurse staffing is
associated with lower rates of UTI
(Cimiotti 2012; Needleman et al 2002).
•More registered nursing hours per
patient is associated with lower rates of
pneumonia and lower rates of delirium
(Cho et al 2003; Kane et al 2007; Kovner &
Harrington 2002; Pappas 2008).
• Less Registered Nurse time per patient
was associated with higher rates of
pressure ulcers (Hickey et al 2004; Horn
et al 2005; Pekkarinen et al 2008; Schubert
et al 2008).
However, the nurses’ role is under
pressure from the increasingly complex
hospital environment and the older
patient population, and may not be
meeting patients’ needs. For example,
nurses have been found to complete 72.3
tasks per hour, with a mean task length of
55 seconds (Westbrook et al 2011); consider
a different patient every six minutes
(Ebright et al 2003); and most report
leaving at least one task undone each shift
(Jones et al 2015).
The most common care tasks left
undone/unfinished are: skin care, mouth
care, toileting/bathing, pain management,
communication and documentation.
Increasingly it is being recognised that we
need skilled providers in complex
environments like hospitals to juggle even
relatively simple interventions (such as
mobility, skin care, hydration,
communication) to complex patients such
as those with dementia.
Nurses offer simultaneous assessment
and intervention to prevent or mitigate
complications. Positive nursing work
environments (including more nurses, or
more RNs) are associated with lower rates
of complications. Yet despite this evidence,
there is an increase in use of non-nurses in
hospitals.
Strategies to improve care
The following strategies are recommended
to improve quality of care for older people
and people with dementia in hospitals:
• Consider the costs of dementia and
complications.
•We don’t want to claim all complications
are the result of neglect or misadventure,
but higher rates can be a strong indicator
that there are opportunities for
improvement. If patients have a higher
risk of a deep vein thrombosis, for
example, the hospital expends more
effort to prevent that. Shouldn’t this be
the same with pneumonia, delirium, UTI
and pressure ulcers? Higher risk means
there’s a need for more preventative
interventions.
• Recognise these four complications as
key quality indicators that are
potentially preventable; measurable at
patient, unit, organisation, state and
country level; related to mobility,
hydration, nutrition, communication,
and hygiene; and related to nursing
workload, skill mix and care rationing.
• Consider nursing as an intervention cost,
rather than a labour cost: if nursing is
considered a labour cost, it is easier to
think that cheaper nurses can mean
cheaper care without changing the
outcomes for patients. But if nursing
work is understood – and further
investigated – as an intervention, then
this would better inform decisions
around hospital efficiency and
expenditure.
•More accurate hospital and state data on
the quality and quantity of bedside
nurses and additional key components
of nursing work environments such as
turnover and burnout, are needed to
improve timely analysis and decision
making that impact on the quality and
cost of patient care.
•Maximise opportunities for quality and
efficiency improvement with the three
sectors that account for most of
Australia’s public health expenditure:
public hospitals; older patients; and
nursing.
In conclusion, there are many
opportunities to improve our
understanding and care of people with
dementia in hospital. Maximising the
value of interactions between people with
dementia and their hospital nurses can be
enhanced if we make better use of patient
outcome data that are sensitive to these
populations. The quality indicators of
UTIs, pneumonia, pressure areas and
delirium are already being used in the
Australian Government-funded Dementia
Care in Hospitals Program being rolled
out across four Australian states. Further
examination of these complex but
important issues in hospital care will be
essential in the prevention of future
suffering, as well as potential
improvements in cost efficiency.
References
The full reference list for this article is available by
emailing the author at
Kasia Bail is Assistant
Professor in Nursing, Health
Research Institute, Synergy
Nursing and Midwifery Research
Centre, University of Canberra.
Her PhD was funded with a
Dementia Collaborative
Research Centre: Assessment
and Better Care Scholarship.
Contact her at:
DCRC SPEC I AL I SSUE : THE B I G P I CTURE I N DEMENT I A RESEARCH