Discussion

This study demonstrates the majority of patients with a behavioural disturbance who receive a C-ART call within the general hospital setting have cognitive impairment such as dementia and delirium, with the majority over the age of 65. This is consistent with an Australian study that found patients with the highest risk of requiring a behaviour emergency response on general surgical, and medical wards have a diagnosis of delirium, closely followed by dementia.25 Similarly, a study in a Sydney hospital found that patients over the age of 65 with behavioural disturbances and requiring emergency intervention, the majority had underlying dementia.26 These findings also align with what is known about patients with dementia and comorbid acute medical and surgical problems, being five times more susceptible to developing a superimposed delirium, thus having multiple risk factors for behavioural disturbance requiring emergency intervention.27

Understanding which patients are at risk of behavioural disturbances within a hospital setting could be very valuable to allow for appropriate resource planning and allocation. In this study, just over two-thirds of the patients requiring a C-ART call had a prior history of aggression and/or BPSD. Hence, a history of physical or verbal aggression is an important predictor for future aggression.28 29 Therefore, an awareness of a patient’s history is vital to identify those at risk, to facilitate early intervention and preventative management.

The study interventions were insufficient to prevent individual patients having multiple C-ART calls. It may be that this population subgroup possess distinct risk factors and hence alternative strategies need to be implemented. This may include a separate team to review patients who have required multiple C-ART calls during an admission for their behavioural disturbance. This team could provide independent and comprehensive assessment and a behaviour management plan without the time constraints and pressure that are present during a C-ART call. As a result of this study, the hospital Deteriorating Patient Committee is exploring development of such a team.

The introduction of a medical officer orientation session was shown to be a valuable resource since approaching and interacting with an aggressive patient can be intimidating. Orientation to C-ART is particularly important given that each health network in New South Wales has different procedures and guidelines to manage patients with behavioural disturbances. Postintervention medical officers displayed a better understanding, confidence and appreciation for C-ART members’ roles and responsibilities, as outlined in the local C-ART Call Guideline. Encouragingly, the medical officer orientation sessions are now adopted as standard practice within the hospital that this audit was conducted.

The Australian Cognitive Impairment Guideline outlines an approach for minimising medication including antipsychotics in the management of behavioural emergencies and emphasises using non-pharmacological interventions as first line. However, there was sustained pressure for medical officers to prescribe sedating medication during C-ART calls. There was a non-significant reduction in the number of patients that required sedation postintervention from 87.7% to 84.4% (p=0.62). This clinical reduction could be due to medical officers becoming more confident in using non-pharmacological de-escalation techniques in line with the Australian Cognitive Impairment Guideline. The data were not sufficient to determine if medication was used in smaller doses or if it was more targeted to symptoms in the postintervention group.

Encouragingly non-pharmacological intervention including verbal and non-verbal de-escalation occurred in over 75% of C-ART calls, both pre and postintervention. This is advantageous for several reasons, but, of particular, importance is the known risks of using psychotropic medications such as benzodiazepines and antipsychotics in the elderly population as they have been associated with increased mortality, stroke and falls.30

We looked at whether detailed instructions were provided to nursing staff post C-ART calls, including a management plan and documentation of important clinical information such as vitals, monitoring level of consciousness, pressure care, fluid balance chart and nutrition notes if sedation was used, as referenced in the Local C-ART Call Guideline. Unfortunately, there was no significant improvement postintervention with preintervention compliance at 33.3% and postintervention at 37.5% (p=0.62). There was no specific intervention that addressed detailed management plans or postsedation care. One suggestion for future quality improvement would be to incorporate postsedation management plans with pharmacological sedation training sessions for doctors.

Both the C-ART Call Guideline and Cognitive Impairment Guideline recommend comprehensive patient assessment to identify (whenever possible) the underlying cause/s of the behavioural disturbance. Compliance with the standard is demonstrated by medical officers documenting a provisional diagnosis and differentials for the behavioural disturbances. When comparing the pre and postintervention groups, there was a clinical increase in compliance with this standard from 36.8% to 65.6% (p=0.73). It could be hypothesised that the prereading material emailed to medical officers prior to term commencement, which highlighting the importance of careful consideration and documentation of a diagnosis and differential diagnosis, may have led to an improvement in compliance with this standard.

Communication between staff is vitally important, to allow for consistent, comprehensive and coordinated care. Postintervention, there was improved communication between medical teams including during daily medical handover meetings as evidenced in postintervention interviews. This has many benefits including elevating the patient with a C-ART call to a high clinical priority for review by the treating team, thus allow for implementation of preventative measures early, exploration of alternatives and ultimately alleviating patient distress. Encouragingly C-ART calls have now become a permanent item on the agenda for medical handover meetings, with the treating team encouraged to refer and seek advice from other clinical experts including geriatric and psychiatric teams when needed. Seeking advice from clinical experts is emphasised in both the C-ART Call Guideline and Cognitive Impairment Guideline.

On the arrival of the C-ART members to a C-ART call, a handover of the patient is required to the C-ART team as stipulated in the C-ART Call Guideline. Unfortunately, handover remained poor post-intervention as demonstrated in postintervention interviews. A different approach to the ward- based education sessions directed at nursing staff may be needed. In the future such sessions could include simulated scenarios allowing participants to practice communication of C-ART handover using ISBAR, under more pressured realistic conditions, to improve expertise and confidence in this area. In the future, consideration would also be given to consultation and inclusion of clinical nurse educators in the development and implementation of education sessions targeting nursing staff, to assist with engagement and utilisation of the material presented.

The file audit demonstrated that postintervention, there was a non-significant increase in implementing clinical and communication tools before and after a C-ART call (p=0.40, p=0.07, respectively). Discussing these tools in the short education sessions may have had a positive influence, these tools form the patient-centred approach that is emphasised in the Cognitive Impairment Guideline.

The use of physical restraint remained high, with no reduction in its use postintervention (p=0.69). Physically restraining a patient is sanctioned in the C-ART Call Guideline, but only in certain critical circumstances, where all alternatives have been exhausted. Physical restraint in the prone position must be kept to the shortest time possible due to the high risk of harm to the patient by way of positional asphyxiation and/or aspiration. However, data collected from the patients’ medical files were not adequate to determine when physical restraint was used, if all alternatives have been exhausted prior to the use of restrain, what type of restraint was used, who performed the restraint and for how long. This could be the focus for a future quality improvement project with the Cognitive Impairment Guideline strongly discouraging physical restraints.18

This study was limited to one small regional hospital in New South Wales, with a relatively small patient cohort. It is acknowledged that findings are site-specific with the approach and procedures used to manage behavioural emergencies likely to differ across health networks in New South Wales and Australia. For this reason, results must be cautiously generalised to other health networks. Additionally, with the small sample size, the study was not sufficiently powered to find statistical differences in the variables between the pre and postintervention cohort of patients (table 3).

Furthermore, the data collection set was limited and relied on the accuracy and quality of documented clinical data. Due to the nature of C-ART calls, that is, often a high stress and chaotic situation, there may have been instances that interventions were implemented but not documented in the patient notes. Time of audit bias should also be considered. Results may have differed if earlier or later months of the year were sampled when clinical staff may have had varying levels of clinical experience and workload.

Interviews were based on volunteers so not all C-ART members were interviewed. Additionally, in the postintervention interview phase, bias could be introduced as non-medical C-ART team members were not interviewed.

Looking towards the future, the uptake of the orientation sessions for doctors could be further improved by running the sessions on multiple occasions throughout a medical term, to capture more staff.

C-ART training could be expanded to include clinical simulation, to recreate the clinical experience of being confronted with a C-ART call scenario, to further enhance communication and management. The clinical simulation could use actors as patients and draw from real-life scenarios for both clinical and non-clinical staff to practice teamwork and management skills under pressure.

Future dedicated education session for doctors on the appropriate use of pharmacological management could also be considered. These sessions conducted by staff specialists could expand on indications, contraindications and possible adverse effects of the use of psychotropics in the management of behavioural emergencies. Sessions could also cover requirements for postsedation monitoring as referenced in the Local C-ART Call Guideline and how this should be documented to comply with the standard. Lanyards with up-to-date information on pharmacological management could also be disturbed across the health network based on the Adult Sedation Guideline.

Debriefing was found to be significantly lacking in both pre and postintervention interviews. This would be a valid component to target in future quality improvement projects, perhaps by dedicating a set time and date each week for C-ART members to discuss prior C-ART call events with a trained facilitator. This would provide an outlet for those involved to process the event, reflect on what went well and what could be improved, to enhance learning opportunities and prevent burn out.

In conclusion, behavioural disturbances in the elderly present many challenges for healthcare staff within a general hospital setting. Patients with multiple behavioural disturbances requiring repeated C-ART calls place high demands on finite resources, and new innovative approaches need to be explored. Further reducing rates of pharmacological sedation and minimising physical restraint of patients receiving C-ART calls should be areas of priority in future projects.

Acknowledgements: I want to thank my mentor Dr Tomiko Barrett for her ongoing guidance and support and the Department of Geriatrics on the Central Coast including the secretarial staff who tirelessly transcribed the interviews.