Acute care

Dr Kirsten posed a sensible question, here, asking how could a patient with delirium be managed better.

I'll post on that, later.

It did get me wondering though, why the question wasn't reversed. Why wasn't an old age psychiatrist asking Dr Kirsten for the advice. No, really, think about it. Our psychiatric hospital has less than a dozen patients with dementia on the wards. Our neighbouring acute hospital Trust has, across it's medical and surgical wards, a lot more. Statistically, I'd expect them to have 334 patients who are older adults with dementia in their beds, today.

334.

That's a lot.

That's common place, that's who they have to look after, each and every day, on their wards. We have less than a dozen on ours.

In-patient care of older adults with dementia; who should the experts be?

Ward doctors

Ward nurses are busy. Medical and surgical wards I visit don't have the staff to do the work that's needed. It's manifestly evident to everyone, but since it costs to pay for more nurses, wards are chronically under-resourced. Our mental health wards are not, thankfully, with a 2:1 patient:staff ratio at the moment.

We staff wards sufficiently 'cause that's what we need to get the work done. Any less and we have worse outcomes.

Our neighbouring acute Trust seems to enjoy collecting data from their medical and surgical directorates. Almost as much as it enjoys documenting events, or non-events. Curiously, it thinks the best people to do this aren't clerical staff or IT staff or medical informatics folk, they reckon it's best to get the nurses to do it. One perk of having nurses on the wards is that they can provide nursing care. On the acute hospital site, I don't see nurses doing a whole heap of nursing now ('cept for the neuro rehab site where they're delightfully anarchic and simply crack on and sort patients, huzzah!) since they're mired in process and paperwork. The Productive Ward has sought to reduce this, but largely hasn't worked on their wards, instead it's generated more process. Ho hum. Maybe it'll get better. They've got less front line nurses and even more Modern Matron managers to sort this out.

Yesterday I saw a lady presenting with confusion, on a medical ward. She had a chest infection, against a background of worsening chronic obstructive pulmonary disease. She had dementia. She had no idea where she was, who was around her, why she was there, how long she'd been there, what was happening, what the different kit around her and the other 3 ladies in her bay was. She had no notion of what day it was, or what time of day.

Ward staff found her difficult to manage, since every 15 to 20 minutes or so she'd anxiously walk to the nursing station, loiter until a nurse passed by, then ask them what she should be doing. It took them time to talk with her. Time they did not have, since their Trust mires them with process that's seemingly more valued than the direct clinical care. They wanted to, but were rushed, they knew they weren't giving her the time she needed and deserved. Much frustration.

But when I saw her, she was settled. She wasn't wandering around the ward, seeking reassaurance any more. She wasn't even sat out in her chair, she was still in her bed. Because the nursing staff had been frazzled, so moaned to the junior doctor. The ward doctor is very young and very inexperienced and has no notion of person centred dementia care. The ward doctor is a doctor and she can prescribe. Haloperidol 10mg had been given, which had flattened her. Spectacularly. Well it would, being about x10 the dose we'd normally give, but ho hum. She was then lying in bed, keeping her nasal cannula on, causing no problems what so ever.

The junior doctor knows no better and can't. She's still too junior.

I get that the junior doctor has to support her nursing colleagues when they're fraught and frazzled. Yet, treating the staff's agenda to the detriment of the patient seems a step too far.

BNF Drugs

I do not have a tablet to stop someone shouting.