Overview
Initiative type
Model of Care
Status
Deliver
Published
June 2026
Summary
To improve hospital care for older adults with dementia and delirium who become distressed and aggressive by developing standardised approaches and care infrastructure.
Dates: January 2025 -
Implementation sites: Queensland Statewide
Aim
To develop a hospital-wide model-of-care framework for safe person-centred management of violence and aggression in patients with dementia and delirium.
Outcomes
- An initial model of care, stratified to tiers of aggression severity, was conceptualised through critical incident informed literature appraisal and two exemplar hospital site reviews
- Site visits to 23-hospital sites across the state engaging 282-multidisciplinary clinicians, revealed systemic gaps and safety risks while confirming the applicability of the proposed tiered-model approach
- Four statewide online workshops (N=175), a national delirium conference workshop (N ~50) and two consumer workshops (N=14) finalised an infrastructure-enabled model-of-care framework.
- The final infrastructure-enabled model-of-care was endorsed for statewide adoption by Queensland Health Senior leadership forum alongside an accompanying hospital service capability tool. Its three-tiered severity stratification requires specific infrastructure: specialist units, cohorting and consultation liaison.
- A statewide gap analysis and heatmap identified nine of 23-hospitals met minimum-or-above capability standards
- For the remainder of hospitals scoring under minimum standards, modest site-specific infrastructure investments were identified that could enable minimum standards statewide.
Background
Violence and aggression in hospitalised older adults with dementia and delirium present major challenges to clinical safety. Dementia and delirium affect approximately 40% of older adults admitted to general medical wards,[1] and approximately 60% of these patients experience behavioural and psychological symptoms of dementia (BPSD). Among those with BPSD, almost 40% experience aggression and agitation.[2] While agitation often manifests as behavioural distress related to acute illness, delirium, pain, or unfamiliar environments,[2, 3] a distinct patient subgroup is admitted because pre-existing aggressive behaviour is too unsafe for community or residential care.[4, 5] General hospital wards are therefore increasingly required to manage a spectrum of high-risk behavioural symptoms in environments not designed for this purpose.[6, 7] Recent assault-related deaths, in multiple hospitals across Queensland underscore serious risks related to the current situation.[8, 9]
Aggression, violence and agitation among people with dementia and delirium arise from neurocircuitry disruptions to an individual’s ability to modulate their response to physiological, psychological, social and environmental stressors.[10-12] In hospitals, aggression and agitation are commonly triggered by multiple stressors located at the patient level (e.g., unmet needs including pain, fear, nutrition, and toileting requirements; psychosis, situational misinterpretations), staff level (e.g., lack of dementia-specific communication and care skills, time pressures, inflexibly scheduled care routines, anxiety, stress), and the environmental level (e.g., unfamiliar, noisy and overstimulating or under stimulating, and suboptimal structure).[13-21] Aggression and agitation are directly associated with increased occupational violence, adverse patient events, length of stay, readmissions, restrictive practices, staffing resources and burden of nursing care.[2, 15, 17, 19, 22-24] Although guidelines for BPSD and delirium recommend minimising psychotropics through person-centred care,[14, 25-27] the appearance of violence on general wards demands immediate safety responses often leaving generalist staff with few alternatives to psychotropic sedation or restrictive practices.[18, 28, 29]. Paradoxically, sedation and restraint can then perpetuate cyclical patient deterioration and intractable behaviour severity.[2, 28]
The evidence regarding person-centred hospital management of symptoms of aggression and agitation in people with dementia and delirium is currently limited by a scarcity of high-quality studies.[14, 30] Infrastructure-enabled models like Specialist Dementia Units (SDUs), geographic cohorting and consultation liaison can each show improved outcomes.[23, 31-39] While, translation to hospital-wide models is yet to occur, [19, 24] the need for hospital-wide frameworks that integrate person-centred care with SDUs and trained workforces has been advocated in the literature.[13, 14, 16, 19, 24, 36]
Methods
Study context and governance
This study was part of a statewide commissioned program—the Practical Redesign Options for Violence in Dementia and Delirium (PROVIDE) project. It was initiated by the state’s Clinical Excellence Department after three independent investigations of assault-related deaths in separate Hospital Health Services (HSSs) identified similar systemic gaps in managing aggression in older medical and surgical patients with dementia and delirium.[8, 9] A multidisciplinary team of three clinical experts (nursing, medicine, and allied health) from different HHSs led the project, overseen by an advisory committee of health department representatives, clinical network chairs and a consumer.
Design and Setting
A multi-stage, mixed-methods design was used and conducted across 16 Health Services in Queensland, encompassing acute and subacute public hospital settings in rural, regional and metropolitan locations. Intensive Care Units, Emergency Departments, and Mental Health Units were excluded, as was a clinical focus on mental health diagnoses, intoxication or substance misuse, acquired brain injury, or cognitive disability. The 5-stage design was guided by the Medical Research Council (MRC) framework for complex interventions, integrating iterative development, stakeholder co-design, systematic model refinement and establishing system capability and readiness.[40] Data collection and co-design activities occurred between 20 January to 29 September 2025.
Project stages
Stage 1: Triangulation of the appraisals of critical-event investigations[8, 9] literature and government reports, and review of exemplar hospitals enabled early synthesis and conceptualisation of an evidence-informed hospital-wide model of care.
Stage 2: Statewide mapping of service capability and iterative codesign and refinement of the model of care involved site visits across 23-hospitals engaging key clinical stakeholders at each site. Site visits comprised a 3-part structure: (1) a 2-hour facilitator-led discussions around barriers, challenges, successes, and practices/processes; (2) an environmental scan of hospital wards was undertaken with a 1-hr hospital walkthrough; and (3) a 1.5-hour iterative workshop in which stakeholders applied the draft framework to their site, with discussions recorded and whiteboard drawings photographed to document adaptations and identify gaps.
Stage 3: A model of care framework was refined and finalised through: (1) four state-wide online 1-hour workshops were conducted with exerts recruited in the stage 2 site-visits; (2) a 1.2-hour breakfast workshop at the Australasian Delirium Association national conference (N~50); and (3) two 2-hour online workshops were conducted with 14-consumer participants with lived experience of dementia and/or delirium.
Stage 4: The PROVIDE clinical leads developed a Health Services Capability Framework to assess statewide system readiness using the final model-of-care structure. Rubrics (scored 1–5) were created for each domain and subdomain, with characteristics and quality descriptors informed by Stage 2 site visits, exemplar sites, and clinical lead experience. A minimum standard score of 3 was set, and domain/subdomain weightings were independently assigned by each lead and reconciled through consensus discussion.
Stage 5: Data from Stage 2 site visits and surveys were applied to the Stage 4 capability rubrics to score hospitals on service capability. Scores were compared across sites and visually represented in a statewide heatmap to support gap analysis.
Discussion
Unsafe hospital management of violence and aggression associated with dementia and delirium represents a predictable system design failure rather than isolated clinical error. Across multiple sites, patients with sustained moderate-to-severe aggression were predominantly managed by generalist staff in standard wards despite limited workforce capability for dementia-care, minimal specialist availability, and care environments poorly aligned with behavioural risk. Prolonged length of stay, multiple near-miss critical events and high workforce burnout were commonly reported. Hospital care was largely reactive and restrictive rather than anticipatory and therapeutic, highlighting the gap between patient need and hospital capacity[2, 19]. These findings supported a call for standardised hospital-wide preparation and approaches.[2, 6, 14, 19, 24, 34]
We applied a multi-stage codesign process to develop an evidence-informed tiered infrastructure-enabled model-of-care, formalising existing but sparsely implemented practices[4, 37-39] into a coherent standardised framework linking behavioural acuity to care setting, workforce capability, and escalation pathways. It reframes aggression and agitation management as a core clinical systems challenge rather than localised behavioural care. Since aggression in dementia and delirium rarely occurs in isolation from other behavioural, psychological and neuropsychiatric symptoms,[41, 42] the model operates as more than a violence-management strategy. Its tiered approach aligns severity to infrastructure-enabled care (e.g., SDUs, and geographic cohorting), creating the necessary conditions for consistent, safe and person-centred dementia and delirium care on both standard and specialist wards across the hospital.[6, 23] Through modest investment in small specialist units the model achieves high-impact relief from violence on standard wards thus enabling targeted, achievable workforce training for each setting.[23] As a result the model is anticipated to address multiple pressure points for hospitals, reducing adverse patient outcomes, occupational violence, staff injury, absenteeism, and burnout, while optimising hospital length of stay, readmissions, and resource utilisation.[2, 17, 22, 23, 43]
To understand current system readiness and capability against this framework, we developed a weighted hospital services capability assessment tool. Applied across 23-hospitals, we identified nine that met the minimum-or-above capability threshold. However, we also identified modest investments that could enable most hospitals to achieve minimum standards into the future. These findings support the framework’s construct validity, as capability scores corresponded to observed variation in specialist availability, training uptake, workforce and dementia-enabling infrastructure. Importantly, the framework demonstrated discriminative capacity across metropolitan and regional contexts as an effective and scalable planning and assurance tool.
Limitations
This was an evidence-informed system co-design project, not a controlled outcomes trial. Therefore, system-level impacts on patient and staff outcomes were not measured and evaluated. Also, findings may reflect state-specific public hospital governance and workforce contexts, possibly limiting direct transferability to other state and country jurisdictions. However, the underlying principles of environment–capability alignment remain broadly relevant. Finally, small regional hospitals (<70-beds) were poorly represented, potentially affecting the model’s applicability to them.
Conclusions
Addressing critical system-level gaps in hospital dementia care, this statewide endorsed model-of-care framework represents a systemic shift away from dispersed generalist care, toward safer more consistent specialised care. Ready for service-level evaluation, the framework can usefully direct hospital redesign, planning, and capability.
Ethics Statement
This study was a quality assurance project involving health service evaluation and audit. It was granted an official ethics waiver for publication by the Metro South Health Human Research (EX/2026/QMS/127396), as meeting the conditions for exemption outlined in the National Statement on Ethical Conduct in Human Research, Chapter 5.1.17.[41]
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Key contact
Dr Frederick Graham, Ms Madeleine Downey, Prof Liz Whiting
Princess Alexandra Hospital
Metro South Hospital and Health service