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Acute Mental Health Assessment Wards

January 27, 2016June 25, 2016 Brett0 comment

Acute mental health assessment and treatment services are an invaluable part of our mental health system in SA. Ward 18 at the Repat Hospital (soon to be moved to Flinders Medical Centre) services the eastern/southern area of Adelaide, Ward SE based at the Queen Elizabeth Hospital covers western suburbs with Ward 1H at Lyell McEwin Hospital covering the north. When patients display violent or extreme/difficult behaviours this ward is the next option after hospital. The public hospitals do their best to control the behaviours but cannot sustain it long term, as the busy hospital environment is not really conducive to people with late stage dementia.

Essentially the public hospitals become temporary ‘holding bays’ and may administer medications to control the behaviours, whilst ensuring the person is medically sound. An ambulance transfer is required to the acute wards and then an interview with staff is had on arrival. This next hour is very important as it is your chance to chat with the senior doctor and nursing staff to discuss the best ways to handle the upcoming care for the patient. Behaviours, triggers and ways to de-escalate situations are all discussed in great detail. You are also given a document called an ‘Inpatient Treatment Order’ (under the Mental Heath Act 2009) refer links below for more information:

https://www.legislation.sa.gov.au/lz/c/a/mental%20health%20act%202009/current/2009.28.un.pdf

http://goo.gl/t7xyl7

k/docs/resources/Mental_Health_Act_Plain_Language_Guide.pdf

The difference with this ward is that there are less beds (approx 8-12), the patients are locked out of their rooms (for safety reasons) and any items that can be considered dangerous are ether confiscated or asked to be removed. This may include electrical items, dressing gown cords, shoe laces and sharp instruments. Bathrooms are locked and patients reside in a main common area with staff based behind a central glassed office area . There is very little stimuli in the ward and is extremely quiet, a welcome change from the very noisy public hospitals (which is better for people with dementia).The wards are very different to hospitals and may appear ‘prison like’ at first due to heavy lockable doors, heavy furniture and a barren environment. The heavy chairs have wheels on them to allow you to move them, televisions are installed behind strong perspex plastic and most doors and cupboards are locked. There are very few items for the patients to be in contact with. They include a handful of magazines, newspapers and their plastic cups, saucers and plates.Quiet activities are locked away in a cupboard to be brought out as required. These measures are to ensure the safety of both the patient and the staff.

There is a nurse allocated to every 1-2 patients and their role is to observe and document the movements and behaviours. The nurses are at risk of being hit at times and it can happen without warning. Patients may sit in silence or cry & shout uncontrollably,push furniture around or may display manic behaviour including pacing and speech issues, which is all part of a day in an acute ward . The patient is rarely out of the gaze of a staff member and they are observed across every 15 minutes (this includes overnight). These wards are a vital part of our health system and need to be in place to ensure people with dementia and others with mental health issues are cared for properly.

10 Days at the Repat Hospital

September 2, 2015October 2, 2016 Brett0 comment

Day 2 was certainly different for us as Mum and I entered the ward with mixed emotions. I kept thinking to myself “Will Dad be agitated or will he be happy?”. When we spotted Dad in the ward he was rapt to see us both. He gave us a huge hug and almost cried. We grabbed the footy and had a few kicks down the corridor like old times. Dad then wanted to sit on the communal couch in front of the tv, where he grabbed the Sunday Mail and started to read it. This was strange because no newspaper has engaged him in the last 12 months.

His speech was more coherent and he was doing plenty of laughing.It was lunchtime so we were ushered into the family room where we watched Dad eat lunch. He had a great meal of roast pork with all the trimmings, and I ate some off his plate as well. I was discreetly video recording Dad whenever he talked so I could capture his mood and behaviour changes. Mobiles are not normally allowed on the ward, but I was I was advised it was ok in the family room as long as I only filmed Dad.

Other patients kept walking in and had to be redirected. As we were in a high dependency ward, we were amongst some psychotic people. One guy told me how he wanted to ‘ slit his wife’s throat’, which was confronting so early in the piece. We enjoyed the lunch and the carer explained how Dad behaved overnight.

The carer then described the fine details of his Detaining Order under the Mental Health Act. This basically meant the State now has full control over Dad and where he ends up, and Dad is not able to be removed from the facility for 7 days when the order will be reviewed. I thought this was pretty over the top and long winded and actually scared Mum. I kept saying to the carer that “we want Dad to be here” ( voluntarily) as we felt he needed a Geriatrician and Psychiatrist’s help, as opposed to standard doctors. I can understand the majority of family members would not want to have their loved one detained, but we are so close to the action that we know this is the safest and best path for Dad.

It is obvious they are very drilled in the ward with a focus on watching patients closely. They follow their every move and are ready for any bad behaviours. It was clear they want to do all the nursing as we are limited to 90 minute visiting times during set hours. They are clearly more skilled carers than any other staff we have seen to date, and are very intense with how they monitor each patient. The ward has a feeling of a jail as the eyes are constantly on everyone’s moves and you need staff to buzz you in and out. The Oxazepam (calming medication)was spread out further to almost tempt Dad to be agitated. This would influence his new medication routines and med timings. We were told he became agitated on the first evening and they gave him a PRN (extra meds).

The following day I had a day off from visiting and enjoyed the lack of responsibility. My sister went in my place and was asked by a carer to help with the showering. Dad was was so confused, they ended up showering him with his tracksuit pants on. They filled up with water, became heavy and this forced Dad to remove them. After the shower and shave, Dad and my sister kicked the footy in the ward, but were getting strange looks from staff. She went and asked if there was a problem and they advised of an incident involving Dad after we left the day before.

Dad was kicking the footy with me on the previous day, and I left the footy on his lap for some comfort when we said goodbye. Not long after we had gone Dad was given a hot cup of tea by a carer. He became confused, thought he was holding his footy and kicked the cuppa like a football. There was a huge drama as the cup broke, mess was everywhere and the place was on edge as it was cleaned up. This really rocked the staff and was the first time Dad ever did anything like this.

The following day I visited Dad at 10.30am and found him in good spirits. I received a huge welcoming hug and my presence gave Dad a big relief. We were ushered into the family visiting room so we could talk alone without other patients intruding. Dad and I ran out of conversation after two minutes and Dad stared at me, smiled, and said ” So….now what?” Then burst into laughter. I decided to put some music on via the chained up cd player. The Elvis cd instantly had Dad dancing around the small room on his own. Every 5-10 minutes a staff member would open the door or peer threw a window to check on us. I was getting the feeling many of the patients in this ward are capable of anything.

I discreetly filmed Dad via my phone as I continue to document his progress and behaviours. I am hoping to catch strings of sentences that make sense and possibly any moods that indicate agitation. Dad is oblivious to being filmed and I was more worried about being caught by the very serious staff as I dont think many people video things. We then setup a game of coits where Dad stood directly over the top of the board and dropped his rings all on the same hook. I asked him to step back to make it harder, but this completely confused him.

I then heard a thump as a male patient hit his forehead onto the glass window and pushed his nose up on the glass and just stared at our every move. I ignored him and handed Dad a pile of CD’s to look through. He was enjoying reading the covers when he grabbed a pile of actual cd’s out of their covers and started throwing them at the board. I stopped him instantly and this indicated to me the level of confusion as he thought he was throwing rings at the coit board. After about 30 minutes we decided to re-enter ‘general population’ where a staff member instantly gravitated to us and began to follow us. Dad started to dance around with me ( which was a first) and then introduced me to others as ” John” which was also the first time ever he has got my name wrong….hmmm.

I mentioned to the carer about the CD incident as a way of explaining how Dad made the mistake with the cup of tea the previous day. I can imagine how the report on Dad would have possibly looked:

INCIDENT: Bob violently kicked crockery and smashed everywhere. Major confusion which upset others.

The way I think it should be reported:

INCIDENT: Bob very confused and mistook full coffee cup for a football. He kicked the cup and broke it causing a scene. Bob was not agitated( non aggressive), was simply confused.

I will never know what they wrote down but I thought it was a great example of how an incident can be subjective and reported in different ways which may result in a medication increase or influence a doctor’s overall assessment. This reporting is something I believe should be standardised to ensure consistency across nursing homes and hospitals.

As Dad was wearing half day clothes, and half pajamas, I asked the carer if I could change him into track pants. They said “ok” but involved an escort, unlocking his bedroom door and bathroom and the carer hovered over me as I struggled to get Dad to understand what I wanted him to do. The carer then said ” Lets leave this till later, as I need to get back to my post”. I am used to being allowed to dress Dad and dealing with his care with no restrictions. The carer finished by saying ” I am glad you struggled with the dressing like we did”. She only gave me two minutes to get him changed, and I explained that difficulty with simple tasks is normal and simply a part of dementia.

As a family we are tired and drained emotionally. We feel guilty when we have a day off from visiting. This ward has very little emotion shown by staff and everything is controlled, and very black & white. We do not have the bond we normally do with care staff as they appear to be intently focused on the patient’s behaviour and do not release much information to us. I believe Dad is behaving at a calmer level than many of the other patients in there and will be returned to his nursing home sooner rather than later.

This is dementia….

Continue reading “10 Days at the Repat Hospital”

Day 1 – Repat Hospital (Mental Health Assessment)

September 1, 2015January 27, 2016 Brett0 comment

Dad arrived at he Repat Hospital and we were blown away by the place. We walked in the door and were met by a carer and a nurse. We were shown to Dad’s private room, which has nothing in it besides a single bed , a cupboard and a bathroom.The room is huge with no television, nothing on the walls, and is pretty bland.

As this is a geriatric ward, safety is paramount and cords on dressing gowns have to be removed, plastic bags are not allowed, and the ensuite bathroom remains locked. Each carer is allocated two patients and there are only 8 beds in the ward. One interesting rule is that during the assessment period the carer must sight their allocated patient every 15 minutes.

Patients are requested to dress in normal clothing (not pajamas) and encouraged to keep out of their room during the day and to spend their time in a common room consisting of a communal tv, couches, a dining area and a secure outside garden. Visiting hours are 10am – 3pm and is preferable if we are not visiting at meal times to reduce distractions.

A blood test and blood pressure check was done instantly to get a starting point for the nursing staff to work with. We discussed some rules and regulations and were told that ” in this ward…we do the nursing for you, and you get to be the family”. This was a huge relief for myself and Mum after 12 solid months of daily caring for Dad.

I knew Dad was in very good hands by the knowledge of the staff and the way they looked after all of us The staff were really friendly and bonded with Dad instantly. The vibe of the ward was one of serenity and the silence was unbelievable in comparison to our time at the RAH (Royal Adelaide Hospital) . They have a security team on site, however they are rarely engaged as the ward staff are trained to handle difficult situations.

The dementia expertise was really evident as the psychiatrist sat in the room with me for almost an hour and discussed all the medications in detail and talked about behaviours and strategies. It was such a pleasure to discuss Dad’s situation with people that really understand dementia and know more than us. In the other hospital (RAH) the nurses are not specialized and are regularly rotated, hence we had to train them on the run in how to deal with dementia patients.

We then met the nurse looking after Dad on his first day, and she sat down with me for over an hour and discussed the fine details about Dad. It was so therapeutic for me to be able to offload and explain every single strategy and tactic we use to care for Dad on a daily basis. I went through all the ‘triggers’ that indicate to us an escalation in agitation and how to best manage them.

It was the fact the staff actually took the time to really listen (with no time pressure), and document every fact which gave us great comfort. I knew that I was not wasting my time, and that the information I provided would be passed on in a detailed handover to each staff member. This meant that they would now be caring for Dad like we would, with the aim of improving his medication management and behaviours to allow him to return to his nursing home.

Dad must have felt like a freshly released prisoner, and was enjoying having the freedom to walk around the ward and interact with patients and staff without restriction. In the RAH he was confined to his tiny space within the ward and was re-directed back to his bed every time he wandered. This went on everyday ( and night) for a month and was exhausting.

The Repat Hospital has a completely different atmosphere and was exactly what Dad needed at this time. We were so impressed with how smooth the transition was and how each team member interacted with us like a well oiled machine. It was almost like the staff adjusted all their plans to make our first day a pleasurable one for all concerned. It certainly was appreciated…..bring on day 2:-)