Supporting the frail and elderly patients at Lakeridge Health

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The overhead pager urgently repeated the words that signaled the need for assistance with a violent patient. Security staff rushed to the room; a nurse was cornered by an enraged patient who was shouting and beating his fists in the air. “Let me out of here. You let me out of here. Where are my keys? You have stolen my keys” he yelled.

Newly admitted to Lakeridge Health’s Post Acute Specialty Services (PASS) unit, Mr. Wilson* was confused, agitated and aggressive. Until recently, he lived at home with his wife, but his behaviour had become increasingly erratic with periods of sullen withdrawal punctuated by unexpected bouts of violent rage. In the past month, he had wandered out of the house and onto the road several times, threatening drivers who slowed down to avoid hitting him. Because he was becoming a danger to himself and to others, he was admitted to the PASS program at Oshawa for assessment, treatment and possible placement.

One year ago, Mr. Wilson’s aggressive behaviour would have been initially managed with observation by security staff, chemical and physical restraints. The safety of Mr. Wilson and hospital staff would have been assured, but at what cost? Within 24 hours of bed restraint, Mr. Wilson’s muscle tone would have deteriorated by five per cent. Moreover, his agitated behaviour would probably have escalated due to the frustration and confusion of being restrained by unfamiliar people in an unfamiliar place. Feeling more like a prisoner than a patient, Mr. Wilson would likely have grown more angry and violent as his bewilderment and isolation increased.

“With the cost of security staff rising more and more each year, we felt there had to be a better way to care for our elderly patients,” says Pat Dingman, Interim Director of the PASS Program, at Lakeridge Health. “In late 2009, Lakeridge Health’s PASS Program implemented a pilot project using (PSWs). The PSWs focus was on de-escalating, redirecting and diverting cognitively challenged patients.” PSWs identified and reduced the triggers that caused agitation and through psychosocial interventions, established relationships that provided some emotional and physical security for their patients.

The pilot proved to be so successful that Lakeridge Health permanently expanded the use of PSWs to other units within the Medicine and PASS programs. Lakeridge Health’s PSW, Dori Nicholson knew as a teen that she wanted to work with the elderly. When her beloved grandfather passed away two years ago after living in a nursing home, Dori knew she needed to put that passion to work. She went back to school, got her PSW certificate and later joined the Lakeridge Health team. She knows firsthand the impact she has on her patients. “For me it’s a discovery and a journey. I love to build a connection with people, solve problems, identify the triggers that aggravate their behaviours and create trust between us. If I can get one smile out of somebody who hasn’t smiled yet, it makes my day.” Smiles aren’t the only outcome of this program.

An audit of the pilot project looked at the use of security staff, physical and chemical restraints as well as the pre and post-behavioural changes of cognitively impaired patients. “Subsequent to the introduction of PSW’s, security usage decreased by 20 per cent and physical restraint usage was reduced by 50 per cent,” explains Beth O’Leary, Quality Excellence Manager at Lakeridge Health. “While, disruptive behaviours attributed to anxiety, agitation, aggression, confusion, restlessness, wandering and elopement decreased on average by 24 per cent and there was a marked improvement in appropriate medication use.”

The use of PSWs in this non-traditional capacity was initially viewed with skepticism by some members of the health-care team; however the success of the program has overcome doubts. In particular, the decrease in eruptive behaviours has allowed physicians and nurses to concentrate on their patients’ complex medical needs with the result that staff are able to utilize their expertise where it can best be applied. Most importantly, patients are calmer and more settled.

The triggers that provoke disruptive behaviours in individuals are documented by the PSWs so that all staff can be aware of and reduce the environmental conditions that agitate their patients. This documentation is also shared with the family, retirement residence or long-term care facility after the patient is discharged so the progress achieved on the PASS or Medicine units can be sustained in the new environment.

Mr. Wilson still has periods of confusion, but he rarely shouts at staff or threatens to hit them anymore. He socializes with other people and often engages in activities that get him up and walking around. Security staff are no longer stationed in the doorway and a restraint is nowhere in sight. When PSW, Dori Nicholson walks into his room, his face breaks into a smile. When Dori sees that, a huge grin spreads across her face too; Mr. Wilson has just made her day. (*a fictitious person)