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2019 inaugural grant funding round

Below are the successful submissions for the 2019 grant funding round. This funding is offered on behalf of the Health Education Australia Limited (HEAL) Foundation, with the project leaders providing a 'work in progress' update at the 2020 AICG Symposium. 

DiVert for Safer Care

Alfred Health

Project leader: Belinda McKay

Medical patients exhibit higher levels of aggression and challenging behaviours that expose staff and themselves to risk and injury. Contributing factors include cognitive impairment due to delirium/dementia, psychiatric co-morbidities, drug and alcohol issues, noise, boredom, anxiety and a change in environment.

New and increasing behaviours of concern (BOC) are usually a sign of deterioration in a person's mental state. A security response, known as 'Code Grey', is frequently the first intervention to manage BOC. A review of 713 Code Grey episodes in 341 Alfred patients showed these were commonly related to psychiatric diagnosis in 35%, dementia or cognitive impairment in 14% and acquired brain injury in 10%.

In 2018 at the Alfred, there were 1935 Code Greys, which equated to on average 5.3 per day. Ward 4 East (4E), a 36-bed general medical ward, had the highest number of Code Grey responses (inpatient wards) with a monthly average of 20 responses. For FY17/18, there were 14 episodes of mechanical restraint on 4E. Restraint poses a risk to patients and results in further MSD. Restraint and Code Greys may contribute to patient distress and increase BOC, in turn impacting on patient/carer experience. 

From 2016-2016 there were 27 reported occupational violence aggressive (OVA) incidents reported on 4E. An OVA survey of 4E nurses found greater than 50% felt unsafe and were not confident in what to do; calling a Code Grey supported their confidence. 

Early response and intervention systems reduce Mental State Deterioration (MSD) and BOC, restrictive interventions and are safer for all. Sensory modulation is a non-pharmacological intervention that assists in the relief of distress and agitation. An early intervention and escalation process (DiVert) that has been introduced in psychiatry and two surgical wards has demonstrated a reduction in Code Greys and restrictive practices. 

This project will further test and refine the DiVert model and strengthen the model by introducing sensory modulation as part of the response; as well as increasing staff capability in early identification, response and management of BOC and MSD.  

Improving the continence status of patients during their in-patient care 

Eastern Health

Project leader: Kathleen Corless

In 2017 and 2018, Eastern Health sought to quantify the relationship between incontinence and hospital-acquired pressure injury. In combination with the annual Pressure Injury Point Prevalence Survey (PIPPS), 1037 patients across acute and subacute in-patient settings were examined for evidence of pressure injury and Incontinence Associated Dermatitis (IAD). The survey highlighted that more than one third 33% of all patients were incontinent and 43% of these patients were identified as having IAD, which is a consistent prevalence rate reported in the literature (Gray M and Giuliano KK, 2018)1.

In addition, the audit team reviewed the use of incontinence associated products across the total patient cohort and discovered that 50% of incontinence products or aids were being used on patients who had not been incontinent in the proceeding 24 hour period. This has raised questions and concerns in relation to appropriate nursing management which supports patients to maintain their continence and independence.

On this background, the baseline data indicates a significant opportunity to enhance care for the older person by reducing the rate of a highly prevalent hospital-acquired risk. This program of work is a new undertaking for the health service and has the potential to benefit patient wellbeing in the short and long term and provide a significant return on investment for the health care system through reducing hospital length of stay and costs associated with consumables.

Establishing an Interprofessional Ward Round Protocol (IWRP) and education program for the diagnosis, risk factor assessment and collaborative management of delirium in post-cardiac surgery patients 

Melbourne Private (Healthscope Australia)

Project leader: Fiona Williams

Patients who undergo cardiac surgery have an increased risk of developing delirium that is associated with many negative consequences, such as increased morbidity and mortality, increased length of stay and poor cognitive and functional decline. The costs associated with delirium are substantial.

The incidence of patients presenting with cognitive impairment post-cardiac surgery is common within the Intensive Care Unit at Melbourne Private Hospital and the step-down Cardiac Ward, resulting in delayed discharge and poor patient outcomes. There is currently no systematic approach to assessing, diagnosing and managing these patients.

The aims of this research are to decrease the incidence and adverse outcomes of post-cardiac surgery delirium. We plan to investigate and implement the use of an evidence-based Interprofessional Ward Round Page 3 of 15 Protocol for the early detection and management of delirium post-cardiac surgery and its associated risk factors. Retrospective and prospective data will be collected to measure patient and organisational outcomes. An economic evaluation will also be conducted. We will identify 10 clinical champions in our organisation to take on the role of supporting clinicians to implement the protocol and a high-quality simulation-based education program will be delivered to these individuals to support their role. A program evaluation of the education will measure educational outcomes and we will explore clinician views and experiences of implementing the IWRP.

Nurse empowerment in residential aged mental health and dementia care: examining the factors to support safe, respectful and quality care 

Chestnut Gardens Aged Care Residential Services (Monash Health)

Project leader: Sarah Davies

Australia's ageing population has resulted in a growing aged care workforce, which is increasingly culturally and linguistically diverse (CALD), with approximately 35% of staff born overseas and speaking English as a second language. In The Avenue at Chestnut Gardens, approximately 72% of staff are from CALD backgrounds.

In addition, approximately 31% of residents in Residential Aged Care (RAC) were born overseas, including in non-English speaking countries. 

Positive relationships between residents, family and staff are an integral part of quality care delivery in RAC settings. The care needs of residents in RAC are increasingly complex due to multi-morbidities, with over 50% of residents having dementia or cognitive impairment. Providing quality care can be challenging for staff and can be further affected by issues related to communication and cross-cultural understanding. Cultural and linguistic concordance between residents, family and staff is viewed as facilitating relationship building.

In contrast, cross-cultural differences between residents and staff may lead to differences in recognising and communicating illness, expectations for care, and resident, family and staff dissatisfaction, all of which can negatively impact on care and quality of life outcomes for residents. 

The new Aged Care Quality Standards will apply to RAC from July 1st, 2019. With a focus on quality outcomes for consumers, the new standards require organisations to demonstrate that their workforce is equipped and supported to deliver safe, respectful and quality care. However, despite the diversity among staff in RAC, there has been limited focus on understanding the experiences and needs of the staff in a dementia and aged mental health-specific RAC setting, with the purpose of empowering staff and building their capacity to provide quality care in this setting, and promoting workplace relationships, including relationships with residents and families.

This is a new project to explore how to support a predominantly CALD workforce to ensure the provision of safe, respectful and quality care for residents in an aged mental health and dementia-specific RAC setting.

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