Nottingham University Hospitals Trust set up a specialist unit so patients with delirium would not have to be treated in noisy and crowded wards

One in three acute hospital admissions is of a confused older person. Many hospital clinicians and managers believe an acute hospital is not the ‘right place’ for frail older people.

However, the vast majority step into an acute hospital seeking treatment for a legitimate medical illness or injury. Most people with dementia admitted to hospital also have delirium, which is a medical emergency. On average, those with dementia have greater illness severity than those without.

Busy, noisy and crowded

Hospital buildings and processes are not designed for confused older people. They are busy, noisy and crowded, with a fast pace of work, multiple moves and new faces, repeated questioning and little involvement of family carers.

These are good reasons for ensuring that there is adequate planning and medical provision in alternative settings. However, when hospital admission is necessary, we can and should do better.  

We established a specialist medical and mental health unit (MMHU) as part of a National Institute for Health Research programme. We developed the acute geriatric medical ward through five main changes (see box)

How Nottingham established its medical and mental health unit

  • Introducing mental health professionals Three mental health nurses and a specialist occupational therapist worked alongside existing staff.
  • Imparting extensive training in delirium, dementia and person-centred care for all staff members Person-centred care means learning about individuals’ personalities, biography, preferences and routines. Measures such as  making the most of patients’ retained abilities, focusing on communication and relationship-building, seeing problems from the patients’ perspective and avoiding confrontation were introduced. This had to be adapted to meet the particular needs of an acute medical ward. Use of time out days, workbooks, external courses and so on.
  • Optimising the environment Noise was reduced, bays painted in distinctive colours, orientation cues and signage were improved, pictures and points of visual interest were introduced, and chairs and sofas placed at the end of bays to encourage mobility and socialising for those well enough.
  • Organising therapeutic and diversionary activities Games, reminiscence, crafts, getting dressed and social eating at a table were encouraged.
  • Adopting a proactive and inclusive approach to family carers We learnt that they were very varied, often stressed and exhausted and could be difficult to engage. However, directly asking about what type and extent of input they wanted, having liberal visiting times and keeping families well informed all helped.

Under the MMHU model, both consultant geriatricians on the ward developed special interests in delirium and dementia. Junior doctors were given additional training and a focus on staff support and team spirit was encouraged. 

Not everything we tried has worked, and the ward has continued to evolve over time. Gratifyingly, several student nurses came back to work on the ward when qualified and the ward is a popular placement for medical trainees.

Testing the model

We evaluated the MMHU in a randomised controlled trial. We compared it with standard hospital care, 70 per cent of which was generic geriatric medicine.

We argued that the effect of a single hospital admission should be seen within 90 days. Our main outcome was “days spent at home”, which takes into account length of stay, deaths, readmissions and new care home placements.

Patients on the specialist unit spent 51 days at home compared with 46 days in standard wards. There were small improvements across all the component parts: mortality was 22 per cent versus 25 per cent, readmission was 32 per cent versus 35 per cent, and new care home admission was 20 per cent versus 28 per cent.

‘We were struck by how frail the patients were. The ward had as much in common with palliative and supportive care than acute medical models.’

We did direct observations to assess patients’ experiences and care quality. Participants on the unit spent more time in a positive mood (79 per cent versus 68 per cent), and four times more staff interactions met emotional and psychological needs.

Family carers were more satisfied with care (91 per cent versus 83 per cent), and severe dissatisfaction was reduced (5 per cent versus 10 per cent). An economic evaluation showed the MMHU was likely to be cost saving overall.

Assessing patients’ feedback

In interviews, family carers recognised that care was different, and better, but still wanted more communication. They also noted that many patients were too ill or frail to engage in activities.

Staff reported that they were more confident and positive about delirium and dementia, and were overwhelmingly appreciative of working alongside mental health professionals.

The ward has attracted a lot of informal attention and praise – from TV, newspapers, local and national politicians, and not least, from grateful family carers.

The way forward

A single ward cannot be the solution to this widespread problem, and we work very closely with the “old age” liaison psychiatry team. But we have shown that better quality of care can be provided. Staff can develop expertise in caring for patients with difficult problems in distressing circumstances. To make this happen, committed leadership, positive attitudes, enhanced skills and some new resources were required. 

We were struck by how frail the patients were, and concluded that the ward had as much in common with palliative and supportive care than acute medical models.

Rowan H Harwood is a consultant and Nicola King is a ward manager at Nottingham University Hospitals Trust.

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