Acute hospital dementia care: results from a national audit.

BACKGROUND: Admission to an acute hospital can be distressing and disorientating for a person with dementia, and is associated with decline in cognitive and functional ability. The objective of this audit was to assess the quality of dementia care in acute hospitals in the Republic of Ireland. METHODS: Across all 35 acute public hospitals, data was collected on care from admission through discharge using a retrospective chart review (n = 660), hospital organisation interview with senior management (n = 35), and ward level organisation interview with ward managers (n = 76). Inclusion criteria included a diagnosis of dementia, and a length of stay greater than 5 days. RESULTS: Most patients received physical assessments, including mobility (89 %), continence (84 %) and pressure sore risk (87 %); however assessment of pain (75 %), and particularly functioning (36 %) was poor. Assessment for cognition (43 %) and delirium (30 %) was inadequate. Most wards have access at least 5 days per week to Liaison Psychiatry (93 %), Geriatric Medicine (84 %), Occupational Therapy (79 %), Speech & Language (81 %), Physiotherapy (99 %), and Palliative Care (89 %) Access to Psychology (9 %), Social Work (53 %), and Continence services (34 %) is limited. Dementia awareness training is provided on induction in only 2 hospitals, and almost half of hospitals did not offer dementia training to doctors (45 %) or nurses (48 %) in the previous 12 months. Staff cover could not be provided on 62 % of wards for attending dementia training. Most wards (84 %) had no dementia champion to guide best practice in care. Discharge planning was not initiated within 24 h of admission in 72 % of cases, less than 40 % had a single plan for discharge recorded, and 33 % of carers received no needs assessment prior to discharge. Length of stay was significantly greater for new discharges to residential care (p < .001). CONCLUSION: Dementia care relating to assessment, access to certain specialist services, staffing levels, training and support, and discharge planning is sub-optimal, which may increase the risk of adverse patient outcomes and the cost of acute care. Areas of good practice are also highlighted.

Symptom Assessment for a Palliative Care Approach in People With Dementia Admitted to Acute Hospitals: Results From a National Audit.

CONTEXT: As the prevalence of dementia increases, more people will need dementia palliative and end-of-life (EOL) care in acute hospitals. Published literature suggests that good quality care is not always provided. OBJECTIVE: To evaluate the prescription of antipsychotics and performance of multidisciplinary assessments relevant to palliative care for people with dementia, including those at EOL, during hospital admission. METHOD: As part of a national audit of dementia care, 660 case notes were reviewed across 35 acute hospitals. RESULTS: In the entire cohort, many assessments essential to dementia palliative care were not performed. Of the total sample, 76 patients died, were documented to be receiving EOL care, and/or were referred for specialist palliative care. In this cohort, even less symptom assessment was performed (eg, no pain assessment in 27%, no delirium screening in 68%, and no mood or behavioral and psychological symptoms of dementia in 93%). In all, 37% had antipsychotic drugs during their admission and 71% of these received a new prescription in hospital, most commonly for "agitation." CONCLUSION: This study suggests a picture of poor symptom assessment and possible inappropriate prescription of antipsychotic medication, including at EOL, hindering the planning and delivery of effective dementia palliative care in acute hospitals.

Differences in the structure of outpatient diabetes care between endocrinologist-led and general physician-led services.

BACKGROUND: Despite a shift in diabetes care internationally from secondary to primary care, diabetes care in the Republic of Ireland remains very hospital-based. Significant variation in the facilities and resources available to hospitals providing outpatient diabetes care have been reported in the UK. The aim of this study was to ascertain the structure of outpatient diabetes care in public hospitals in the Republic of Ireland and whether differences existed in services provided across hospitals. METHODS: We conducted a cross sectional observational study of the 36 public general hospitals providing adult outpatient diabetes care in the Republic of Ireland. Data relating to numbers of specialist medical, nursing and allied health professionals, waiting times for new and return patients, patterns of discharge back to primary care and engagement in quality improvement initiatives were recorded. RESULTS: Thirty-five of the 36 eligible hospitals participated in the study. Sixty percent of these had at least one consultant endocrinologist in post, otherwise care delivery was led by a general physician. Waiting times for newly diagnosed patients exceeded six months in 30% of hospitals and this was higher where an endocrinologist was in place (47% V 7%, p = 0.013). Endocrinologists were more likely to have developed subspecialty clinics, access to allied health professionals and engage more in quality improvement initiatives but less likely to discharge patients back to primary care than general physicians (76 v 29%, p = 0.005). CONCLUSIONS: Variations exist in the structure and provision of diabetes care in Irish hospitals. Endocrinology-led services have more developed subspecialty structures and access to specialist allied health professionals and engage more in quality improvement initiatives. Nonetheless, waiting times are longer and discharge rates to primary care are lower than for non-specialty led services. Further studies to determine the extent to which case-mix variation accounts for these observations are warranted. Aspects of hospital-based outpatient care could be developed further to ensure equitable services are provided nationally. At a time when the delivery of diabetes services in primary care is being promoted, further research is warranted on the factors influencing the successful transition to primary care.

Diabetes care in Ireland: a survey of general practitioners.

AIM: To investigate the organisation of diabetes care in general practice in Ireland and identify areas for future development. METHODS: Survey of a representative sample of 600 general practitioners (GPs). The questionnaire contained closed and open-ended questions addressing 4 topics; characteristics of the practice, diabetes care delivery, use of services and opportunities for developing diabetes care. RESULTS: The response rate was 44% (n=262). There were an additional 86 responses to a follow-up shortened version of the survey resulting in a 58% response rate for 9 key questions. The majority of respondents were from an urban (43%, n=112) or a mixed area (39%, n=101) and 19% of practices were single-handed (n=66). The reported prevalence in participating practices was 0.7% for Type 1 diabetes and 2.8% for Type 2 diabetes. Forty-five percent of GPs maintained a diabetes register (n=157) while 53% reported using guidelines (n=140). A formal call recall system was reported by 30% (n=78) with a further 20% (n=54) reporting a regular if informal approach to calling patients for review. With regard to the use of diabetes related services 63% reported direct access to a dietician (n=165), 57% direct access to chiropody services (n=149) and 89% had direct access to retinopathy screening (n=234). There was a significant association between maintaining a diabetes register and other aspects of care delivery such as engaging in formal recall (p<0.001), using guidelines (p<0.001) and a declared special interest in diabetes (p=0.001). Of a number of choices 75% of GPs thought that training was the principal opportunity for improving diabetes care. In response to the open-ended questions GPs cited lack of resources, time constraints and workload as barriers to effective care delivery. CONCLUSIONS: Delivery of diabetes care in Ireland remains largely unstructured. Key challenges to improving diabetes care appear to extend to the system and organisational level of care delivery.