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A novel integrated care pathway for people with dementia presenting to acute hospitals

Authors: Suzanne Timmons , Mary Mannix, Margaret McKiernan, Maria Connolly, Mary J Foley, Siobhan Cahill, Aoife Ni Chorcorain

Abstract Introduction: Almost 30% of older people admitted to acute hospitals in Ireland have dementia, but only 1/3 of these have a known diagnosis in the community. Thus hospital staff are often treating patients with dementia without knowing it. Acute hospitalisation is a pivotal time for a person with dementia, associated with longer length of stay, poor assessment by hospital staff of the dementia, and often discharge to long-term care post hospitalisation. No hospital in Ireland had a functioning dementia care pathway in 2014. Practice change implemented: Introduction of a novel dementia pathway in an acute hospital as follows: all older people (≥70 years) screened for cognitive vulnerability (delirium, dementia, or delirium on dementia) on admission to hospital; patients with known dementia following a novel dementia pathway throughout their hospital stay, including daily delirium screening and a dementia care bundle, and an in-reach community dementia service to allow seamless post-discharge support; enhanced communication with community at time of discharge; patients with suspected dementia following a novel diagnostic pathway with streamlined access to diagnostic clinics and post-diagnostic support in the community.Aim and theory of change: A dementia pathway would improve the detection of cognitive vulnerability and the prevention/detection of delirium and would also standardise and improve integrated care.Targeted population: People with dementia or possible dementia presenting to an acute hospital; stakeholders: hospital staff (especially nurses), patients, carers, hospital management; community based healthcare workers and managersTimeline: Preparation (literature review, process mapping of patient journey through hospital and into community; staff and stakeholder engagement; development of pathway with wide consultation and input): 1 year; piloting and modification of pathway on a single ward: 6 months; roll-out to other wards: 6 months.Highlights: (innovation, Impact and outcomes) The pathway development process was robust and was a partnership with multiple hospital stakeholders, including patients and carers, and the community with a consrtium of 45 people across the hospital and community working together. The pathway incorporated national delirium screening algorithms and for the Emergency Department, a combined dementia/delirium care bundle was developed to meet their need for a simple, easy-to-administer bundle that could be used even when the diagnosis of dementia and/or delirium was not yet clear. Existing community based services were used, but enhanced communication and a novel in-reach community dementia service led to integrated discharge planning and post discharge support. The impact and outcomes are being evaluated by an external agency currently.Comments on sustainability: This pathway functions ideally with a dementia nurse specialist at its core, but can be used without this post in place. It bundles together core nursing activities, with some small areas of new practice (daily delirium screening, enhanced information gathering via a patient “passport”) which have been sustained in the participating wards thus far.Comments on transferability: This pathway was designed to be transferrable to other acute hospitals and community areas in Ireland with minor adaptations only.


dementia, integrated care pathway, care bundle, hospital, delirium

How to Cite:

Timmons S, Mannix M, McKiernan M, Connolly M, Foley MJ, Cahill S, et al.. A novel integrated care pathway for people with dementia presenting to acute hospitals. International Journal of Integrated Care. 2017;17(5):A417.

DOI: on 17th October 2017