Wednesday, November 12, 2014

TOP 5 is tops!

As noted below, I've been having a wonderful time meeting with folks at the New South Wales Clinical Excellence Commission.  This is an agency with a broad-ranging agenda to improve the safety and quality of patient based care in Australia's largest state.

The CEC has a slew of initiatives, and I thought I would share one with you from their Partnering with Patients program.  The overall objective of PwP is to include patients and family as care team members to promote safety and quality.

The particular program I present here is called TOP 5.  It is lovely in its simplicity and low cost . . . and in the power of its results. It could be replicated anywhere there is a will. 

The idea is to come up with strategies to help caregivers who are responsible for dealing with people with dementia--and particularly the anxiety and agitation that can characterize this disease in the presence of certain environmental factors.  As described by the CEC, "TOP 5 is a simple process that encourages health professionals to engage with carers to gain non-clinical information to help personalise care. This information is then made available to every member of the care team, thus improving communication."

5 strategies are developed after consultation between staff and the carer to ensure they are workable in the ward setting. The agreed strategies are recorded on an identifiable TOP 5 form and included in the patient's bed chart notes, enabling all staff to access this information and support the care provided. Up to five strategies may be recorded, however, in some cases there may only be one or two relevant strategies.

Dr. Karen Luxford, Director, Patient Based Care, and Anne Axam, the project coordinator, kindly gave me some examples, which I summarize here:

One gentleman had been a paramedic.  All the "bells and whistles" that are typical in a community hospital setting only escalated his anxiety:  He felt he needed to jump into action at a each "emergency." The strategy that was developed was to speak to him as if he were member of the team--using professional terminology--and advise him that "another car is responding." He would then become settled. 

Another example was Mr. G, a very gentle and proud man, who would become very agitated after his shower. "A discussion with his wife helped us learn that he became very upset if he did not have his watch on his wrist. She always made sure it was replaced as soon as possible." The strategy that was developed was that, during his shower, the staff would reassure Mr G that they would put his watch back on after he was dry, and then they would put his watch back on as soon as possible. With his watch on his wrist he did not become agitated. 

A third example.  A gentleman (Bob) without a primary carer was admitted to the service. He used to get very agitated each morning at 4:30 and was very difficult to settle. One day a visitor came into the room and recognised Bob. The staff asked the visitor if he knew anything about Bob that might explain his daily agitation. He was able to shed some light on the situation: Bob used to manage a delivery yard and part of his job was to get the trucks on the road by 4:30am. The strategy adopted was for the staff to just say, "Bob, the trucks are all gone" and he would settle down. 

Beyond this reduction of anxiety, which is reason enough to run the program, I look forward to learning more about the possible clinical benefits of TOP 5.  The program reminds me of a similar approach adopted in Saskatchewan to help avoid falls among the elderly with dementia. One success story involved a gentleman who regularly fell, usually when experiencing stress.

The staff noticed that the man enjoyed being engaged in small motor physical tasks and also being near the staff.  In fact, when both occurred, his stress levels were noticably lower. So the staff invented a task for the man, repeatedly putting pennies into a cup, and they arranged for him to be in frequent proximity to the staff.  In the months since they organized this approach, he has had no falls whatsoever.

I'm willing to bet that we'll hear similar results from the CEC, and I look forward to their future reports on this program and other initiatives.

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