The number of seniors in Ontario continues to rise and has grown by 1.1 million in the past two decades. At Humber River Hospital (HRH), 73% of admissions are seniors. This population is at an increased risk for comorbidities and dementia, with the risk of dementia doubling every 5-years between the ages of 65 to 84 years.
Dementia is closely associated with responsive/expressive behaviours, which can be defined as a person's actions, words and gestures responding to something important in their personal, social or physical environment. These behaviours can be highly visible incidents of physical expressions of risk such as hitting, grabbing, pushing, and throwing things, or less visible expressions such as anxiety, depression, withdrawal or unwillingness to accept day-to-day care.
In the acute care setting, the exhibition of responsive behaviours in patients can create barriers to discharge as their next level of care may not be able to manage those behaviours, resulting in a longer length of stay. It is essential to identify signs of behaviours early during a patient's stay, accurately identifying specific behaviours and triggers, and developing a care plan that will improve patient outcomes, patient experience, reduce acute care utilization, and improve provider experience – Quadruple Aim.
The Behavioural Supports Ontario - Dementia Observation System (BSO-DOS©) is a tool that enables clinicians to observe trends in behaviours and develop individualized behavioural plans for patients. This tool provides accurate data about a patient's behaviours throughout each 24-hour cycle over a period of several consecutive days, with data that can be used to identify patterns and contributing factors associated with responsive behaviours, enabling the development of a behavioural support plan to address unmet patient needs through activities, environments, approaches and/or medications. Successfully managing patient behaviours can allow for the timely transition of patients from hospital, to their next level of care.
Current documentation of the BSO-DOS© is paper-based, with opportunity to leverage technology to better capture data, and allow for a systematic review of trends generated from observations and triggers, supporting the development and implementation of more accurate behavioural care plans, for great impact and outcomes.
Humber River Hospital (HRH) is the first acute care hospital in Ontario to automate the Behavioural BSO-DOS© in the Electronic Medical Record (EMR) Meditech, in partnership with Behavioural Supports Ontario. The automation of the BSO-DOS© was part of a Dementia and Responsive Behaviours Pilot Project on the Acute Care of the Elderly (ACE) inpatient medicine unit.
This initiative occurred between February 22, 2021 to May 14, 2021 and sought to build competencies in nursing staff on techniques and strategies to care for patients with responsive behaviours, as well as train staff on the utilization of this automated solution. This pilot included a structured 12-week hospital education and training program carried out in partnership with LOFT Behavioural Support Transition Resource team, the Regional Geriatric Program (RGP) and Alzheimer Society, which was well received by staff. Nurses with a baseline knowledge in Gentle Persuasive Approaches (GPA) found synergies between educational programs enhancing their learning. Furthermore, leadership provided by LOFT helped support the translation of knowledge from theory to practice. Following pilot evaluation, this initiative will be scaled across additional inpatient medicine units.
The BSO-DOS© was incorporated into nursing documentation screens in Meditech transitioning the paper tool into an electronic version – eBSO-DOS©. This solution leverages HRHs digital infrastructure and electronic point-of-care system improving documentation and compliance, and has opened up opportunities to utilize other features of the Meditech EMR including the use of clinical panels to view trends over a period of days. This solution has built capacity within the clinical team to better identify trends in responsive behaviours and create more accurate behavioural support plans to better meet unmet needs of patients to manage behaviours allowing them to return home to the community, congregate or institutional settings. Automation of this solution allows for reporting on compliance and outcomes, supporting sustainability and high reliability care.
"This initiative will greatly enhance safe and compassionate care of our vulnerable elderly patients and their families by empowering their care team to more accurately identify and respond to existing or new behaviours through individualized approaches to care." Beatrise Edelstein, Program Director, Seniors Care, Inpatient Medicine, Allied Health & Ambulatory Services.