Recognising and responding to cognitive impairment in emergency care

Aims and Objectives:

The aim of this project was to develop training for ambulance staff on a person-centred approach to the recognition and management of persons with dementia (PWD) in order to improve emergency care and dementia diagnosis. This was designed as a qualitative, three phase study with members of staff, PWD and their carers

Phase 1

A literature review of training for ambulance and emergency medical services staff regarding patients with cognitive impairment was carried out. We completed a systematic review of the published literature to determine the nature and extent of research in this area. The aim of the review was two-fold: first, to find research on the recognition of dementia by ambulance staff; and second, to determine if there are existing interventions to help ambulance staff improve the management of people with cognitive impairment. The review was complemented by a national internet-based survey of all UK ambulance services through the National Ambulance Audit Steering Group. The purpose of the survey was to determine the nature, intended purpose and method of delivery of dementia training for ambulance staff.

Main findings

There is a marked absence of published research regarding training and interventions for ambulance staff on PWD accessing emergency ambulance services. No research directly related to improving the recognition of PWD by ambulance staff was identified. The search returned 168 papers, but only 19 had any relevance and none were directly related to improving the recognition of patients with cognitive impairment by ambulance staff. The most relevant research described tools for paramedics to assess pain in cognitively impaired patients. A national survey of all eleven UK ambulance services for information on the nature and purpose of dementia training for staff returned only three responses.

However, following the end of the study, a launch event for a new training resource was held. The 'Stand by Me' DVD based education and resource pack was originally developed in 2011 as a means of improving communication and care for people with dementia.   This resource has been extremely successful and is now being launched as a free online training resource by the Association for Dementia Studies, University of Warwick, working with Skills for Health. This has the potential to reach a wider audience and provide opportunities for frontline practitioners, including paramedics, to reflect on and improve their practice.

Phase 2

Phase 2 used workshops and interviews with staff and carers of PWD to hold structured discussions and explore experiences that could be built into scenarios to use in the training package.  This was a qualitative study with paramedics and carers of PWD to investigate experiences of paramedics attending dementia patients and the experiences of PWD and their carers in accessing the ambulance service.

Paramedics were employees of South Western Ambulance Service NHS Foundation Trust (SWASFT) and were recruited as volunteers in response to an invitation published in SWASFT's Trust bulletin. Paramedic participants took part in workshops which were facilitated by the researcher and an independent qualitative researcher and held at SWASFT training premises. 

Main findings

Although the priority for paramedics is the identification and treatment of urgent care needs, they regularly find themselves assessing patients for dementia; often informally. The main concern of carers was that they needed to call an ambulance as a last resort in order to access health services, even when they felt that this was inappropriate, due to a lack of alternatives. Paramedics often convey a PWD to A&E due to a lack of more appropriate options for care, rather than a lack of knowledge or training. Paramedics who participated in the workshops felt that although they had no requirement for additional dementia training, they did feel that training would be very appropriate for student paramedics as they find that younger or newer co-workers have less understanding of the issues involved in attending a PWD. The experiences shared by paramedics during the workshops have been used to modify and build upon the training package, previously applied in primary care, for use with student paramedics. 

Phase 3

Phase 3 was a co-design consultation process with patient, carer and public partners.  A Research Event for Patient and Public Partners was organised and run with support from the South West Crucible. The event was a forum for members of the public to meet with researchers and find out about dementia research in the West of England.  It can be difficult to engage with patients and carers for dementia research for a number of reasons, including the progression and burden of the illness. The idea of this event was to engage with any members of the public who have an interest in dementia - for example, they may know someone with dementia or are worried that they might be at risk of developing the disease - in order to inform, direct and shape ongoing and future research. Leading scientists from the West of England and Wales gave focussed 10 minute talks about their research.

Members of the public were asked for their opinion on the research, and had the opportunity to sign up to hear more about dementia research.

Main findings

It was consistently difficult to engage with PWD throughout this project.  Despite adopting multiple approaches to recruitment and obtaining the necessary approvals, no PWD actually participated. We were able to engage with carers of PWD and interviews with them were used to inform the training materials. In terms of meeting the objective of exploring ethical issues, and the preferences of patients and carers, relating to pre-hospital identification of cognitive impairment, transfer of information to primary and secondary care and a timely diagnosis of dementia, it was not possible to complete this work. However, through the FORGETWest Event, we were able to engage sufficiently with PWD and their carers to start building PPI for future projects. The event was attended by approximately 80 people and feedback on the event was extremely positive.  We partnered with the Dementia HIT PPI team to engage with attendees and 25 Volunteer Panel sign-up forms were given out at the event and further information has been sent out to 70 people. The Dementia HIT web site now contains 'PPI Guidelines' with a 'Volunteer Panel Information' section.

Impact

We are now working with the Paramedic Programme Leader at the University of the West of England to further refine the training materials developed during this study, and anticipate that they will be introduced as part of the learning programme for student paramedics at UWE in the 2015/16 academic year.

A successful research event for patient and public partners: FORGETwest: Find Out about dementia Research; GET involved (West of England), was run at the UWE Conference Centre on 31st March 2015. We intend to continue to provide the FORGETWest as a regular (e.g. annual or biennial) event.

An application to NIHR RfPB planned for May 2015: Home or Hospital for People with Multimorbidities including Dementia: What is the potential to reduce avoidable emergency admissions? £150,000.

Outputs

Papers published: