Improving the Transition to Home for Dementia Patients

At Queensway Carleton Hospital (QCH), we proudly serve an aging community. With Geriatrics as one of our cornerstone programs, our team is always committed to taking care and improving the lives of aging patients from the moment they set foot into QCH and beyond.

One of those improvements came from Christine Cook, a Registered Nurse (RN) from our Acute Care of the Elderly (ACE) Unit. Her idea on improving patient care turned into a quality improvement project reflecting the significant need for hospitals to improve the transition home for patients with dementia. Especially when associated with Behavioral and Psychological Symptoms of Dementia (BPSD).

This project was selected out of a group of applications from across Ontario to receive an Advanced Clinical Practice Fellowship (ACPF) grant of $15,000 from the Registered Nurses Association of Ontario (RNAO) in March, right as the pandemic hit.

But COVID-19 did not stop Christine from working to improve patient care.

In collaboration with many frontline team members including nurses, geriatricians, geriatric nursing specialists and clinical management, Christine found new ways to communicate our care planning information and provide a safer discharge home for our patients.

Early in the project, Christine spoke with patients’ families and care partners, our community partners at retirement homes and long-term care homes, and with our frontline staff.

“I was consistently hearing from our community partners that we needed to increase communication and information sharing around planning care and the transition home for this vulnerable demographic. We needed to do better to serve these patients.” – Christine Cook, QCH Registered Nurse 

Christine Cook, QCH Registered Nurse & ACFP Grant Recipient

Christine went straight to work by taking an existing informal patient care plan tool, reviewed it and expanded it to include a section for unit-to-unit transfers. This new added section serves as a reminder to communicate vital information about specific and unique behaviors, triggers, and techniques to help the patient feel more safe and secure. In turn, this promotes safe transitions for both the patient and staff. It also reminds our nurses to send the care plan with the patient on transfer to another unit and on discharge back to the community.

This Care Plan is becoming a permanent part of the electronic patient chart and will be formally approved as a new tool at QCH.

In addition, the medicine discharge tool will be revised to include the option to select dementia as a health problem. Christine developed a new discharge checklist, as a means to help nursing staff streamline their discharge process. This checklist will become a gold standard for patients with BPSD in providing clear direction on steps in preparation for discharge. This will give the nurses standard work to complete, ensuring more consistency in the information being shared.

Christine’s project will change the transition to the community for patients suffering from dementia and will create a sustainable and high-quality means to discharge them home safely, and with better satisfaction for the patient’s care team.

QCH is very grateful to the Registered Nurses Association of Ontario (RNAO) for this amazing nursing opportunity. It has provided QCH the possibility to improve care for one of our most vulnerable patient populations and for their care partners. Thank you Christine for your incredible contributions to our hospital and community.