EXECUTIVE SUMMARY
Dementia poses a threat to patient safety in several ways. Detecting dementia is the first step in addressing the risk.
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Risk managers should ensure that all patients older than 65 are screened for dementia.
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A popular screening tool takes only three minutes to administer.
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Wandering and incorrect information are major concerns.
(This is part one of a two-part series on the risk management and patient safety implications of treating patients with dementia. This month’s issue explores the risks such as acting on incorrect information from the patient. Next month, we will address how to comply with the Health Insurance Portability and Accountability Act.)
Growing concern about the patient safety risks posed by dementia is prompting some U.S. healthcare systems to address the issue with policies and procedures designed to avoid misinformation and other threats.
The prevalence of dementia increases with age, with estimates ranging from 1% to 2% of adults at age 65 up to a high of 30% by age 85, according to the Alzheimer’s Association. Physicians fail to recognize dementia in 19% to 67% of patients in the outpatient setting, the Alzheimer’s Association reports.
A primary concern with dementia patients is receiving incorrect or incomplete information from them and basing care decisions on that bad data, says Marcus Escobedo, MPA, senior program officer with The John A. Hartford Foundation in New York City, which focuses on improving the care of older adults. But in addition, dementia increases the risk of wandering, complicates communicating with the patient, and may interfere with nutrition if the patient refuses to eat properly, he notes. Falls also are greatly increased with dementia patients.
“This is a huge risk. Patients with dementia are at greatly increased risk for everything from medication errors to elopement, and healthcare providers often do not realize how great that risk is,” Escobedo says. “These are patients that require an increased level attention in all aspects of healthcare.”
Healthcare professionals and staff members also can be at risk because patients with dementia can be physically abusive in response to their confusion, fear, and agitation, Escobedo says.
The Pennsylvania Patient Safety Authority began investigating patient safety threats from dementia when a patient’s family member reported several near misses prompted by the patient providing incorrect information to hospital staff, says Michelle Feil, MSN, RN, CPPS, senior patient safety analyst with the Authority, in Harrisburg. Feil recently authored a report on the problem and potential risk reduction strategies. (The report is available online at http://bit.ly/1YdxyY6.)
Healthcare facilities reported 3,710 events through the Pennsylvania Patient Safety Reporting System between January 2005 and December 2014 involving patients with dementia or potentially unrecognized dementia, she found, and 63 were traced to hospital staff obtaining inaccurate information or consent from these patients.
Feil and her colleagues identified these five ways in which dementia led to patient safety concerns:
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failure to recognize pre-existing dementia;
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failure to assess competence and decision-making capacity of patients with dementia;
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failure to identify a reliable historian or surrogate decision-maker for patients with dementia;
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failure to contact a reliable historian or surrogate decision-maker when information or consent was required for care;
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failure to communicate the patient’s dementia diagnosis, competence, and decision-making capacity with all members of the healthcare team.
Detection is key
Detecting the dementia is the first step to avoiding patient safety risks, Feil says.
“Risk managers have to make sure that clinicians have a process in place to screen patients for cognitive impairment,” she says. “Any patient 65 years or older should be screened on admission. It’s a problem that goes undetected because the patient or family may be unaware or in denial, or perhaps it is not as obvious when they are home in a familiar environment.”
Escobedo agrees, and he notes that hospitals and healthcare systems instituting routine screening for older patients have detected much higher rates of dementia than otherwise would have been documented.
Feil recommends the Mini-Cog screening tool, which takes about three minutes to administer. (The tool is available online at http://bit.ly/1UynKpO.) The family member who reported the problem to the Pennsylvania Patient Safety Authority lobbied for hospitals to use a black wristband to denote dementia risk, but hospitals resisted adding another wristband color after recent efforts to standardize the wristbands, Feil says. Instead, some hospitals are using a special sticker that can be added to any wristband for a patient with cognitive impairment, and similar notifications can be placed at the bedside or on the door to the patient’s room.
Healthcare professionals must be careful, however, not to assume cognitive impairment with all elderly patients, Feil notes. Doing so would be disrespectful and deprive patients of their autonomy. Even when a patient does have dementia, Feil says, they still should be allowed to make decisions that do not affect their health or safety.
Dementia can go unnoticed in healthcare settings even when it is documented, Feil points out. The primary physician may have noted the dementia diagnosis in the patient’s record, but other members of a multidisciplinary team may not notice and will accept inaccurate information from the patient. That bad information then is entered into the patient’s record and can lead to patient harm.
Family members can help
Once dementia is known, the healthcare team should work closely with a family member or friend who is familiar with the patient’s condition, Escobedo advises. In addition to helping provide correct information, this caregiver can help avoid situations in which the patient becomes agitated and removes tubing or fights someone trying to provide a bath or other care.
“It is important to have a system in place to identify those family members or friends and bring them into all conversations about the treatment or goals of the patient,” he says. “Behavioral problems should be turned around and seen as expressions of unmet needs, and it’s the role of the provider to determine what those needs might be by talking to the family caregiver about what is comforting, what is agitating, what helps the person remain calm in certain situations.”
If the conditions stipulated by the power of attorney have been met, then that person now has the authority to make decisions for the patient.
Some hospitals place dementia patients in rooms that have a clear line of sight from the nursing station, which helps prevent wandering and other potentially dangerous behavior, Escobedo says. Medications also should be monitored to avoid those that are known to worsen dementia symptoms, he says.
There are best practices for older patients and delirium that can be helpful in improving patient safety. One Escobedo recommends is the Hospital Elder Life Program (HELP) developed at Yale University in New Haven, CT, which uses volunteers, staff training, and protocols that are designed to keep patients engaged and safe. (For more information on HELP, see the resources at the end of this article.)
“The first hurdle is getting people to realize that dementia poses this kind of risk that is not found with all patients, or even all elderly patients,” Escobedo says. “Once that risk is known, there are effective ways to address it.”
Sources
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Marcus Escobedo, MPA, Senior Program Officer, The John A. Hartford Foundation, New York City. Phone: (212) 832-7788.
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Michelle Feil, MSN, RN, CPPS, Senior Patient Safety Analyst, Pennsylvania Patient Safety Authority, Harrisburg. Phone: (717) 346-0469.
RESOURCES
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The Nursing Home Toolkit is provided by the University of Pittsburgh (PA) School of Nursing. The Toolkit contains resources to help staff in senior living communities promote non-pharmacologic behavioral health strategies to address behavioral and psychological symptoms of distress that occur in long-term care, especially among residents with dementia. The toolkit is available online at http://bit.ly/1rFyAxN.
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A fact sheet from the Hartford Institute for Geriatric Nursing at New York University in New York City explains how dementia can complicate care. The sheet is available at http://bit.ly/1TqXYBJ.
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The Hospital Elder Life Program (HELP) in Boston is a patient care program that promotes optimal care for older adults in the hospital. Information on HELP is available online at http://bit.ly/1NiERx7.
