Dementia Awareness by Julie Garton

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Dementia Awareness Week runs this year from 4 – 10 June. There are lots of events across the region supported by a wide range of individuals and organisations. This year, I’ll be promoting the use of a document called ‘This Is Me’ within acute hospitals and asking Dementia Champions and other colleagues across NHS Dumfries & Galloway settings to join in.

When someone with dementia comes into hospital, a care home or is receiving care at home, they and their family/friends may be asked if they have a ‘This is Me’ document.

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What Is ‘This Is Me’?

‘This Is Me’ is intended for use by anybody with dementia, delirium or other communication impairment.

It aims to provide important personal information about the person from their perspective and those who know them best (family/caregiver) to help enhance the care and support given when the person is in an unfamiliar environment.  It’s crucial that we understand the person as an individual and take their personal history into account, helping us to communicate and engage with the person, which in turn can help us to prevent/alleviate stress and distress.

What are the benefits of ‘This Is Me’?

For the person, their families/caregiversif the person with dementia has memory and/or communication problems, then a ‘This Is Me’ guides and supports staff to provide care in a way that respects the person’s choices, preferences and routines. ‘This Is Me’ can be a great opportunity to ask and find out information, that as family members we may not know – provoking good memories and conversation. In addition, a ‘This Is Me’ or similar may reassure people with dementia and their caregivers that we see behind the dementia and respect that person.

For stafffor professionals, it can help us deliver person centred care, and importantly, reduce the times we ask for the same information – the detective work has already been done.

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Where can ‘This Is Me’ be used?

‘This Is Me’ can be used anywhere, in hospital, care homes, in primary care, respite care and is offered during Post Diagnostic Support.

When should it be completed?

‘This is Me’ always offered during Post Diagnostic Support but can be completed at any time.

Are there issues around confidentiality/sharing this document?

The document is the property of the person and/or their main care giver – it is not a clinical document and does not belong to any professional or service, the person/care giver decides what information is included and shared.

Once completed, the document should be kept in a place that is easily accessible for those providing care, for example, at the bedside, in a care plan. The information can help staff understand the persons’ baseline abilities, lifestyle, routines, likes/dislikes and gives great opportunities for conversation and engaging with the person.

What happens to the form if/when the person is discharged or transferred?

As it belongs to the person, it should go with them on discharge/transfer, and it’s also useful to check with the person and /or their main carer that the information remains up to date and relevant.

Living Well with Dementia

It’s important to understand that many people are able to live well with dementia, leading active and fulfilling lives for years after they first experience difficulties and receive a diagnosis, but coming into hospital can be daunting for all of us, and for people with dementia , this can be a frightening experience.

Whilst these days, a person with dementia may only be in hospital for a short time, how we communicate and support them will have an influence on the impact of the whole care experience and how quickly they can return home. We know that older people with dementia are more likely to be discharged to a care home than older people without dementia, have longer hospital stays and experience more falls and pressure ulcers.

We know that in Scotland around 93,000 people are living with dementia and we think around 25% of all acute hospital beds are occupied by people with dementia (Alzheimer’s Research UK, 2018), yet mostly, people arrive into our services without a document such as This is Me even if they have one at home.

“This is Me gives me golden information about an individual. The nuggets of information are priceless in helping to smooth the way to getting to know the person behind the dementia”

Gillian, Staff Nurse

‘This Is Me’ is just one of a range of tools that can support centred care, Getting to Know Me, Life Story work and a wide range of personal profile tools are available, many online, helping professionals to see the person, not just the patient.

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I ‘m keen to hear about your experience/s of using This Is Me in your workplace – please contact me or, if  you would like more information about This is Me or would like a copy, please contact me at jgarton@nhs.net or 01387 246981.

Julie Garton, Alzheimer Scotland Dementia Nurse Consultant

Dietitians do Prevention by Laura King

Laura King 1Next week sees the return of Dietitians’ week and the theme this year is ‘Dietitians do Prevention’ with each day having sub-themes. Follow #DietitiansWeek on Twitter, Facebook and Instagram for some insights into our involvement in a wide and varied range of preventative activities.

Here in NHS D&G we have dietetic teams working across these areas which may come as surprise to the majority of folk working in the acute hospital who perhaps associate us mainly with artificial feeding and oral nutritional supplements for those who have scored 2 or more when nutritional screening is done on the wards.

As a small team we recognise that we have to play a role in educating and enabling patients, their families and carers to prevent over and under nutrition by supporting self-management, the dietitian can’t come shopping with you, cook your meals and help you to eat them and make the best choices, so we have to rely on using our communication skills to educate and inform patients and those close to them to help have a healthy, balanced diet that meets their needs.

We factor in ‘what matters to you’ and our assessments incorporate a huge range of factors as this poster illustrates:

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Our Team works in the following areas all of which have significant roles to play in prevention:

Community Nutrition Support  (Kerry, Alexandra, Jackie, Jennifer, Lis, Dillon and Carole) – We provide practical, evidence based dietary advice, specifically tailored to each individual. Through dietary advice we aim to prevent and treat a wide range of medical conditions and empower people to make appropriate diet and lifestyle choices. Community Dietitians see patients in a variety of settings including community hospitals, nursing and residential homes, clinics and patient’s own homes. Our role identifies, prevents and manages malnutrition in the community. We liase with individuals to create realistic and achievable goals to optimise/improve their dietary intake.

Various medical conditions require an individual to be provided with their nutrition via a tube. We are responsible for managing these patients in the community, either in their own home or in a nursing home/community hospital setting.

We deliver educational talks on various topics including cardiac rehabilitation, stroke, Parkinsons disease and pulmonary rehabilitation.

Renal (Fiona) – Supporting patients with advanced kidney disease in managing complex nutritional requirements. Preventing further complications that can arise from inability to excrete electrolytes and fluid overload as well as avoiding weight and muscle loss for this group of patients who have increased requirements for protein once dialysis has commenced.

Gastro (Gemma and Sarah) – Preventing complications from poor management of coeliac disease such as the obvious GI disturbances through to the ‘hidden’ consequences such as increased risk of bowel cancer and oesteoporosis. Supporting patients living with inflammatory bowel disease to manage their symptoms and optimise their health and well being. Preventing the often crippling effects of irritable bowel syndrome by supporting patients to use the low FODMAP diet to identify trigger foods and modify their diets in a safe and sustainable way.  Preventing malnutrition in liver disease which is often masked by fluid shifts.

Paediatrics (Mhari, Anne and Tracey)  – Supporting parents & their child in managing children with complex needs, tube feeding, diabetes, gastroenterology issues, cystic fibrosis, weight management, faltering growth and allergies – preventing short and long term consequences of under nutrition.

Diabetes (Katy, Nicola, Sally, Sheena, Wendy): We are an integral part of the diabetes multi-disciplinary team providing a dynamic and evidence based service. We deliver quality assured education, and aim to support patient driven care and safe self management to those living with diabetes and their family. We also provide continuing education and support for health care professionals working with individuals with diabetes.

Weight Management (Katy, Nicola, Sally, Sheena, Wendy): We provide person centred, safe and evidence based advice to individuals with complex needs and requirements. This encompasses a variety of approaches to help aid weight loss and improve quality of life.

Mental Health and eating disorders (Sam and James) – Supporting recovery from mental health crises and from the consequences of living with disordered eating behaviours.

Catering (Debbie)- Working with Catering to achieve menus for inpatients across the region that offer a varied, balanced diet to support their recovery and prevent complications such as poor wound healing and  pressure ulcers. Also ensuring guidance for Catering teams to create therapeutic or special menus for patients’ individual dietary requirements. Training staff who make and deliver food, fluid and nutritional care to patients in hospital.

Acute (Laura, Anneka, Laura, Jennifer, Laura and Sheree) – seeing patients identified as being at risk of undernutrition to assess their individual needs and support recovery. Preventing increased length of stay, poor wound healing, pressure ulcers and other complications of malnutrition and providing advice for discharge to help patients stay well and continue their recovery once home with or without the support of the community dietitians as appropriate.

All this activity is coordinated and supported by our Head of Dietetics (Lorna).

The acute team are planning to pilot some staff education sessions on B3 and D7 to support ward staff in preventing malnutrition as well as identifying the patients who need our one-to-one support, so please get in touch with Dietetics on 01387 241568 if you would like to know more, want to arrange any training on your wards or if you have any questions about this blog post and what we do.

Meanwhile here are some pictures of the acute team (Anneka, Jennifer, Laura and Laura) ….

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Laura King is Lead Acute Dietitian at Dumfries and Galloway Royal Infirmary

What Matters by Ken Donaldson & Alastair McAlpine

I recognise that it is a bit cheeky of me to put my name to this as I haven’t written any of it. A few months back I was scrolling through Twitter and came upon this thread that really moved me. The messages are simple yet immensely powerful. I have therefore simply taken some screenshots from Twitter and published them here. As you can see this is by a Doctor called Alastair McAlpine who is a Palliative Paediatrician in Cape Town, South Africa. Read on…..

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Cant Thank Everyone Enough

You don’t have to look very far these days to realise that the NHS is under significant pressure; the local bulletins, national news and local papers are all talking about ‘Winter Pressures’ and ‘Flu Outbreaks.’ This, along with staff shortages and capacity issues, would make many of us dread going in to hospital or having a loved one admitted however I recently had to witness my husband spend the festive period in the new DGRI and I was so impressed by his, and my, care that I wanted to write about it.

On the 19th of December my husband was referred up to X-Ray for a CXR. This rapidly became a CT scan and then direct admission to the Combined Assessment Unit. This itself was a massive shock for all of us and a very scary time. However the staff in X-ray were amazing and made a frightening experience a tiny bit more acceptable by their kindness and attention. Thank you to all of them.

When we arrived on CAU it was obvious that it was a very busy place. For the staff to be working under this pressure in a new environment beggars belief but they did so with equanimity and charm. The care my husband got was excellent and I wish to thank Moira and all the other nurses who were fantastic as well as the Health Care Support Workers (many cups of tea which were never too much bother) and also Drs Ali and Oates. Dr Oates your visit on Christmas Day meant a great deal to us.

After CAU we moved up to Ward B2 and the outstanding care continued. I came in at 8.30am and left at 9pm and having a single room and open visiting meant I was able to stay with my Husband at all times which meant so much to us especially during this time of uncertainty. We could cry in private and talk in a way we could never have in a 4 bedded bay. Once again the staff were amazing – all the staff nurses, HCSWs and Domestics got used to seeing me around and, despite being extremely busy over Christmas and New Year, catered to our needs. They brought blankets and cups of tea – the small things which can mean so much – without us having to ask, in fact they were so busy we would not have asked for anything. Dr Gysin listened to our moans with patience and kindness and ensured that my husband got home as soon as possible, just after New Year.

We have just started a journey which will now mean trips to Edinburgh for more tests and possible treatment. This was always going to be a hard time but the caring and compassion we experienced whilst in DGRI over the festive period has made it that little more bearable.

Thank you

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The Pneumonia in Bed 5 by Sian Finlay

Although it is sometimes easy to forget it amongst the busyness of front line clinical duties, I am a person.  I suspect many of you are too.  Occasionally I am unwell, but I consistently find that I still remain a person during this period – I have never yet become a disease!  So why is it that when patients come into our care, we so often default to calling them by their diagnosis instead of their name?  Go onto any ward and I guarantee it will not be long before you hear someone described as ‘The Chest Pain’ or ‘The Pneumonia’.  Many handovers will include phrases such as ‘He’s a UTI’.

No, he isn’t! He’s a PERSON who has a UTI!

A common (and potentially even worse) variant of this is the ‘bed number’ name, exemplified by ‘Bed 3 needs the commode!’  Sometimes attempts are made to justify this practice with the excuse that it protects confidentiality, but let’s be honest here.  The truth is that it simply demands more mental effort to remember the patient’s name and we are taking a short cut.  All very understandable in a busy environment, and I really don’t blame anyone.  You might think it is just semantics anyway – what does it matter if we call someone ‘The GI bleeder’?  Well I argue that it does matter.   More than you think.  These patients are people, no less complex and emotional and fragile than you or me.  By depersonalising them, we are subtly starting down a path which allows us to forget this; which allows us to view them as tasks in our day rather than the individuals they are.  If you are unconvinced, try this little exercise; read these 2 sentences and see if they elicit the same emotional response in you:

Bed 5 is agitated.

Tommy is agitated.

Would you agree that the second sentence immediately makes us feel more empathy and compassion towards its subject?

Many people will be aware of the late Kate Granger, the inspirational doctor who responded to her diagnosis of terminal cancer by establishing the ‘Hello, my name is..’ campaign.  Sadly Kate died last year, but her campaign lives on and has touched many of us in the healthcare profession.  But Kate’s work didn’t begin and end with wearing a smiley badge with our name on it; it is in essence about remembering the humanity of our patients and treating them as fellow human beings.  And I can only imagine Kate’s fiery reaction if she ever overheard herself being referred to as ‘Bed 5’!!

But we are all under pressure.  What if we genuinely can’t remember the patient’s name and are just trying to communicate information quickly?  Surely that doesn’t make us uncaring?  Of course it doesn’t, but in times of acute amnesia, we could at least say ‘the man with pneumonia’ rather than ‘the pneumonia’.  And that should only be a holding measure until we can remember his actual name – surely essential for safe communication anyway!

I hope I have convinced you that words do matter.  The phrases we use set the whole tone for the level of kindness and empathy we expect in our clinical areas.  So if any of this resonates with you, I hope you will lead by example.  Look at your patients and remember they have hopes and fears and histories and personalities…and almost always names!!

Sian Finlay (aka ‘The Migraine on ward 7’) Acute Physician and Clinical Director for Medicine at NHS Dumfries and Galloway

 

 

Surviving and Thriving in a Time of Change by Dawn Allan

I have always been fascinated by human beings and why we are the way we are.

Does our cultural and family background influence us?

Why do some people believe in God and some don’t?

Why are some people able to talk about death and dying so easily?

Why do people focus on their weaknesses, what about their strengths?

How self aware are we?

Who are we when nobody is looking?

Having emigrated from Ayrshire to South Africa where I spent my childhood and early adult years, I discovered the down side of the school playground because I sounded different.  There were only so many times a 6 year old with an Ayrshire accent wanted to mandatory repeat the word ‘potato’ at the class bullies insistence, and then suffer his disparaging comments,

“…doesn’t she sound weird…say it [potato] again…oh, ja, you’re from ’SCOT-LAND’ hey…”!?!

I remember stifling back tears, wishing I sounded like my peers so he would leave me alone.  When I reflect on this childhood bullying memory, it is mainly laughable now and I quickly adapted by adopting a local accent to blend in.  Life nurtured resilience and I learned when it might be safe to confront a bully wisely, when to ignore them and when to ask for help.

This year I relocated from Shetland to live and work in a place, “Often described as “Scotland in Miniature,” South West Scotland’s Dumfries & Galloway region is characterised by its rich cultural heritage, stunning scenery, sweeping seascapes, towering cliffs, rolling agricultural land, and its wide, wild landscapes”.  Who wouldn’t want to live here?!?  So, what about the people?  I am pleased to say they too are fascinating, warm and welcoming.

The 2017 focus for NHS Dumfries & Galloway is the move for many staff from the current DGRI to the new hospital.  From what I am gathering, this process of change is daunting for some.  If communication is key to all that we offer and provide as health care professionals, part of the way we manage our expectations in preparing to move is to be aware of how we communicate with or about each other as individuals, departments and teams.  Having a person-centred approach should be our modus operandi – our behaviour and communication does not go un-noticed by patients and visitors.  Being a ‘relational person’, I believe our hospitality is as valuable as our clinical / social care, our administration skills or our financial targets.

If a holistic approach cares for the whole person, this includes acknowledging someone’s pain, providing them with pain relief and offering them a cup of tea – all spiritual ‘acts’.  We all deliver spiritual care, what I aim to define is that we as staff do not, ‘go Greek’ i.e. compartmentalise and separate a person into ‘bits’, i.e. age, gender, status, patient, service-user, client, spiritual, religious, physical, mental, psychological, emotional…When in physical pain, the whole of our being is affected.  Judeo-Christian views that –

  • every person is born with worth and dignity
  • every person has the ability to choose between doing good and doing wrong
  • every person has the responsibility to help others in need and the community

Whether the person we are caring for or working alongside has a belief / faith or not, they will have a ‘value system’.  I hope having a VBRP – Values Based Reflective Practice – approach will help all of us as we reflect and hopefully learn from the past in the present, to know how to continue or change best practice, including our communication.  Our motives are based on values we apply every day which will help or harm the people we care for, including ourselves.

To be a hopeful presence is how I sometimes describe my encounters with people.   When we are at our most fragile and vulnerable, we need others we can trust, who will listen with their eyes and ears, who can make us laugh, encourage us when we feel stressed, sick or lonely and offer compassion.  My confidential support includes staff – we are all at different stages in our professional roles and our personal lives.  Before anyone ever declares whether they have a belief / faith or not, it is what we have in common as human beings that is paramount.  Difference is a given, but negative overemphasis on difference marginalises people – companionship and inclusion build bridges.  Sometimes, ‘life happens’ and it is the sudden, unexpected occurrences that affect our health and relationships most.

One of my favourite authors C S Lewis reminds me that a man of such academic, creative gravitas was honestly transparent, he said, “I pray because I can’t help myself.  I pray because I’m helpless.  I pray because the need flows out of me all the time – waking and sleeping.  It doesn’t change God – it changes me.”

Rabbi Harold Kushner’s description speaks into my role, “When you cannot fix what is broken, you can help very profoundly by sitting down and helping someone cry.  A person who is suffering does not want explanation: the person wants consolation.  Not reasons, but reassurance.”

If we as individuals think we do not need each other, we are deluding ourselves.  My faith informs my professional practice, without imposing it on anyone.  If the Son of God relied on twelve disciples, who am I to say I can survive without the support and wise counsel of colleagues?  We are only human and we need each other to ensure NHS Dumfries & Galloway not only survives but thrives today and tomorrow.

Dawn Allan is Spiritual Care Lead Chaplain at NHS Dumfries and Galloway

Improving Patient Flow by Chris Isles

Dave Pedley gave an excellent talk two Wednesdays ago on Tackling Crowding in Emergency Departments, triggered no doubt by the number of times recently we have been running at 100% bed occupancy with patients sitting in chairs in the Emergency Department because there were no free cubicles.

The nightmare scenario for us all as the clock ticks inexorably towards December 2017 is that the same thing happens when our fabulous new hospital opens and the TV cameras, newspapers and journalists begin to salivate at the prospect that something goes wrong (there will be no story to report if the transition to the new hospital goes smoothly and there are no corridor patients).

The chances that something could go wrong are actually quite high and the problem is almost entirely medical by which I mean the large number of frail older people living precariously in the community who fall, become immobile, incontinent or delirious and require at least some form of assessment but often admission to hospital.

The omens are not good.  Dumfries and Galloway has the second highest proportion of people in Scotland who are aged 75+ and living alone.  Our Health Intelligence Unit have shown that despite numerous initiatives and new ways of doing things the Medical Unit would be sailing perilously close to 100% bed occupancy if we moved into the new hospital today. (See me previous blog on the new hospital here)

During his talk Dr Pedley showed a powerful 5 minute video by Musgrove Park Hospital in Somerset entitled Tackling Exit Block ie their hospital’s inability to move patients through ED because of numerous interrelated system failures.  (https://youtube/WX1YwKIkWzA).  Musgrove Park ‘s Top Ten Reasons Why People Cant Leave Hospital were as follows:

  1. Discharge delayed so patient can have lunch
  2. Carer/relative can’t pick them up till after work
  3. Nurses too busy looking after other patients to arrange discharge
  4. Waiting for transport or refusing to leave without free transport
  5. Waiting for pharmacy
  6. Waiting for ward round
  7. Waiting for blood or scan results
  8. Waiting for discharge letters
  9. Packages of care planned for late afternoon/early evening
  10. Patient doesn’t want to go to the assigned bed in community hospital

During discussion a number of solutions to our own recurrent difficulties with patient flow were proposed.  These included tackling all of the above in addition to attempting to educate the public about when and when not to attend ED.  My own view is that this might be as fruitless as King Canute sitting in his throne on the beach and attempting to stop the incoming tide on the grounds that any patient who comes up to ED and is prepared to wait up to 4 hours and possibly more to see a doctor or a nurse must feel they have a very good reason to be there (one often quoted reason being that they could not get an appointment to see their GP).

There were some illuminating moments.  We asked Patsy Pattie whether Dynamic Daily Discharge was still as effective as it had been when it was first rolled out.  She replied that some wards needed support on embedding the process.  Dr Pedley praised staff for their firefighting skills on those occasions when patients were unable to access cubicles in ED which prompted Philip Jones, our chairman, to say that a corporate rather than firefighting response was needed.  Many heads nodded in agreement.

A corporate response might mean fixing lots of little things in order to make patients flow through the system more speedily.  Dynamic Daily Discharge could then become an established part of ward routine rather than an optional extra; the paperwork in the medical assessment area might need to be simplified to allow nurses to move patients into the body of the ward more quickly; a nurse on each ward might be designated to carry the ward phone rather than allow it to ring endlessly in the hope that someone else will pick it up; clinical teams would actively consider how patients might get home;  consider community detox for alcohol withdrawal; patients earmarked for discharge might move to the dayroom unless physically unable to do so; hospital taxis might take people home if relatives or patient transport cannot do so; patients could be issued with a prescription to take to their local pharmacy if new medications are required or go home with immediate discharge letter to follow if not.

To these solutions I would add fully funded Ambulatory Emergency Care and Comprehensive Geriatric Assessment services together with more and better social care and a commitment to fill the hospital with more staff on public holidays (of which there will be four within one month of the new hospital opening).

The Chief Executive of Musgrove Hospital finished her contribution to the Exit Block video by saying ‘we need every single member of staff to understand their responsibility in ensuring patients flow through our hospital so that we can discharge them home as quickly and as safely as possible’.  Who could disagree?

Professor Chris Isles is Sub-dean for Medical Education and is a Locum Acute Physician.