Cognitive Impairment Rounding

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Initiative Type
Model of Care
Status
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Summary

A new model of care Cognitive Impairment Rounding was proposed and subsequently implemented by the then Acting Nurse Unit Manager at the Logan Hospital. This involves one Enrolled Nurse (grade 3) per shift allocated to implement structured rounding on six patients identified to have or be at risk of delirium in addition to the primary care nurse. The rounding nurse solely focuses on implementing the evidence based strategies review to prevent or treat delirium.

This initiative was a finalist in the Pursuing Innovation category at the 2017 Queensland Health Awards for Excellence.

Key dates
Jan 2017
Dec 2017
Implementation sites
Logan Hospital

Aim

Improved consistency of care for cognitively impaired patients.

Benefits

  • Reduced length of stay
  • Reduced hospital readmissions
  • Elimination of ‘specialling’ as a barrier for discharge.

Background

Ward 3A is a busy acute medical ward that traditionally used one-to-one or cohort ‘specials’ in addition to the primary care nurse, to provide care for patients with a cognitive impairment. These patients were often considered high fall risks, wandering and at risk of absconding or simply required more nursing hours due to delirium. This model of care failed to deliver satisfactory patient outcomes.

Solutions Implemented

  • Activities for stimulating cognition
  • Mobilisation and exercises
  • Carer/family involvement in care
  • Communication with patient and family
  • Elimination
  • Hydration and nutrition
  • Pain assessment and pain relief
  • Regular orientation and reassurance
  • Increase sensory input and reduce sensory overload
  • Fall prevention strategies
  • Pressure injury prevention strategies.

Evaluation and Results

Since the model’s commencement on ward 3A there has been a 69 per cent decrease in the number of incidents of occupational violence with an average of 1.5 incidents per month compared to 4.8 incidents per month prior to the implementation. Falls have decreased by 7 per cent and hospital-acquired pressure injuries have decreased by 47 per cent.  These figures translate to fiscal benefits for the health service particularly in the reduction in expenditure caused by the consequences of suboptimal care such as hospital-acquired pressure injuries and occupational violence associated work cover claims.

There has been a reduction of 7.7 per cent Hours Per Patient Day (HPPD) and a reduction in the use of casual staff by 13.5 per cent. An associated decrease in the use of specials from an average 1,895 hours per month to 1,234 hours per month has been demonstrated, and a decreased length of stay (LOS) for the cognitively impaired patient from an average length of stay of 29 days pre-CIR to an average of 21 days post-implementation.

Lessons Learnt

  1. Previous experience with cohorting of patients often led to a chaotic environment, therefore the new cognitive impairment rounding model initially tended to keep ‘enrolled’ patients separate throughout the ward. However, it has been found that with this model of care patients can be allocated together in the same bed bay without escalation of behaviour and the time allocated to these patients can often be shared in more meaningful activities.
  2. Firmer criteria for those allocated to the cognitive impairment rounding model and ‘discharging’ off the model is required to give more clarity to the shift coordinators. It has been identified already that there are often more patients that would be suitable for the model than is available spaces. This has led to patients who have had fewer behavioural issues whilst on the rounding model being ‘discharged’ from the rounding only to have these behaviours escalate again.

     

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Key contact

Meryl Banister
Clinical Nurse Project Officer
Metro South Hospital and Health Service
(07) 3089 2817
Meryl.Banister@health.qld.gov.au

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