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E-observation software helps identify high-risk patients with cognitive impairment at Portsmouth

Research teams at Portsmouth Hospitals NHS Trust have used routine data collected using an e-observation system to conduct a retrospective study into unscheduled admissions of patients aged 75+. They found that patients with cognitive impairment, but no previous diagnosis of dementia, had similar outcomes to those with diagnosed dementia – with a comparable risk of dying in hospital to patients with dementia, and longer lengths of stay.

Dementia screening, malnutrition screening and NEWS scores collected within System C’s CareFlow Vitals system (formerly known as Vitalpac) was linked with data from the Trust’s patient administration system on length of stay and discharge destination to identify vulnerable patients and understand their outcomes.

Outcome

The Trust can now use the research findings to improve processes and person-centred care to reduce adverse outcomes for example:

  • Education for nurses and doctors on the importance of improved detection of cognitively impaired older people without a dementia diagnosis
  • Improve planning of appropriate clinical services
  • A ‘red tray’ meal system to highlight to staff patients that need extra assistance with feeding
  • More systematic use of a ‘forget-me-not’ symbol to highlight patients who are known to have dementia

Timeline

The Trust started using the CareFlow Vitals system hospital-wide in 2010.  Electronic screening for dementia began in January 2014. The analysis looked at data between January 2014 and October 2015, and was carried out by Portsmouth Hospitals NHS Trust in partnership with the Wessex Collaboration for Leadership in Applied Health Research and Care.

Rationale

Portsmouth was aware that older people with dementia admitted to hospital for acute illness have increased mortality and longer stays compared to those without dementia.  Cognitive impairment (CI) is common in older people and the Trust suspected there might also be increased risk of poor outcomes for these patients but there was no large-scale data or research to confirm its theory. 

Solution

The Trust decided to conduct its own research to understand the characteristics of this patient group and determine whether their mortality and length of stay is similar to patients with dementia using the routinely collected dementia screening data. This data is collected electronically by staff using CareFlow Vitals on handheld devices

Patient Screening Data

Patients with a known diagnosis of dementia were identified. For patients with no known diagnosis of dementia, the following questions were asked:

  1. Is the patient exhibiting disturbed behaviour?
  2. Has the patient been increasingly forgetful over the last 12 months so that it has had an impact on their daily life? If the answer to one or both questions is ‘yes’, an Abbreviated Mental Test Score (AMTS) was performed. Delirium is also recorded if present in patients with disturbed behaviour.

Vitals data

Vital signs (temperature, systolic blood pressure, pulse, respiratory rate, consciousness level, oxygen saturation, use of supplemental oxygen) are recorded electronically via the Vitals software and a National Early Warning Score (NEWS) of 0–20 was generated. The NEWS score indicates the patient's risk of deterioration and death within the next 24 hours. Malnutrition Universal Screening Tool (MUST) scores and Body Mass Index (BMI) were recorded.

Demographic data, admission route, admitting specialty, admission and discharge dates, diagnoses (International Classification of Disease 10), death in hospital and discharge destination were entered into the Trust’s patient administration system from clinical notes.

The results

The research found that admission characteristics, mortality and length of stay of patients with CI resembled patients with diagnosed dementia. Whilst attention has been focused on the need for additional support for people with dementia, patients with CI, which may include those with undiagnosed dementia or delirium, appear to have equally bad outcomes from hospitalisation.

Of 19,269 unscheduled hospital admissions, the data revealed 11.6% of admissions of patients aged ≥75 were cognitively impaired but had no prior diagnosis of dementia. These patients had similar demographics and acuity at admission to patients with dementia. Both groups had high rates of nutritional risk and a significantly higher risk of dying in hospital than patients with no CI. The length of stay for patients with CI was significantly longer than those with a prior diagnosis of dementia, and more patients were discharged to further hospital care.

The improvements and benefits

The valuable insights the data showed has helped the Trust to make the following improvements and release associated benefits:

Early / systematic detection of CI at admission

The research highlighted the need to improve the detection of cognitively impaired older people without a dementia diagnosis in order to reduce length of stay and mortality rates and to trigger further assessments. 

Early detection of CI allows the Trust to transfer the patient to appropriate wards where staff are more familiar with managing their needs, i.e. Medicine for Older People wards, so the patient can receive specialised care quicker.

Improved management in hospital

The Trust is now using the Vitals system in real-time to detect a patient with CI and adopt better management whilst in hospital.  Once the software detects a patient it is used to monitor closely for patient deterioration and escalate care if necessary to avoid death in hospital. Discharge needs are raised earlier to allow engagement with the necessary services to shorten hospital stay.

Offer person-centred care and policies

Person-centred care and policies for people with dementia may also be appropriate for CI patients and have been adopted.  For example, a ‘red tray’ meals system is used to indicate to staff those patients that need extra support with feeding and should be encouraged and helped to eat as much as possible.

Patients with an AMTS of eight or below are referred to the GP for assessment at discharge. This enables more detailed assessment in a primary care setting, earlier provision of appropriate care in the community and earlier assessment and diagnosis of dementia.

The full research report can be read here.