Introduction to
‘Immediate management of delirium care
bundle’ and change package
Karen Goudie, Clinical Advisor
a
Michelle Miller, Improvement Advisor
Healthcare Improvement Scotland
Delirium Patient Story
• Video from European Delirium Association
Population of Scotland
Delirium
• Older People are frequently labelled as
confused on admission and throughout
hospital stay
• Delirium is a disturbance of consciousness,
attention, cognition and perception that
develops over a short period of time. It is a
serious condition associated with poor
outcomes.
• Delirium is a Medical Emergency that
warrants immediate attention from staff
Delirium
• The prevalence of delirium in people on
medical wards in hospital is about 20% - 30%
• 10%-50% of people having surgery develop
delirium
• The incidence of delirium will vary across
clinical areas
• Reporting of delirium in the UK is poor
indicating that awareness and reporting
procedures need to be improved
People who develop delirium may
• Need to stay in hospital longer
• Have increased incidence of dementia
• Have more hospital-acquired complications
such as falls and pressure sores
• More likely to need to be admitted to long
term care if they are in hospital
• More likely to die (NICE, 2011)
Identification
4AT Tool
Delirium Immediate Care Bundle
Guidance (first 2 hours)
TRIGGERS
Severe illness
INVESTIGATE
FBC, U&Es, CRP. LFTs Glucose,
Mg, Ca+,phos, Consider ABG
MANAGE
First and foremost treat
underlying causes
Manage sepsis
Trauma/surgery
Pain
Infection/Sepsis
Dehydration
Hypoxia
Hypoglycaemia
Culture Urine, sputum,
wounds , Consider Blood
Culture (Sepsis Six) CXR
urinalysis
Refer to The SDA Pathway for
complete care guidance
Provide environmental and
personal orientation
Frailty
Always carry out routine
Observations (EWS) including
AVPU and Think glucose.
Do Not
Alcohol and drugs withdrawal
Start Fluid Balance
Use Restraint
Urinary Retention
/Constipation
Think about Hydration Status
Do not Sedate Routinely (See
SDA Pathway)
Medication s
Refer to Scottish Delirium Association for complete care pathway
EXPLAIN
Families and Carers Can
give you a history of
change always speak to
them to obtain history
and baseline function
Families and Carers can
help reorient
Always Document
Delirium Diagnosis
Assess Capacity
Consider AWI Form
(section 47)
Improving Care for Older People in Acute Care: Delirium Driver Diagram
Primary Drivers
Aim
To improve the
identification and
immediate
management of
delirium for
people aged 75
and over being
admitted to acute
care, by March
2014, to achieve
95% compliance
with all elements
of the care bundle.
Think Delirium Identification of
Delirium
Immediate
Management of
delirium
Education,
leadership and
culture
Secondary Drivers
Think Delirium - Screening on admission to identify delirium
•Screening of patients over 75 years being admitted to acute care, to identify delirium,
using a screening tool (eg 4AT)
•Document diagnosis of delirium (where positive screening)
•Create a culture that supports family and carer involvement in care
•Promote the use of patient, family, carer feedback to improve care
•Ensure patient requirements are accurately reflected in the care plan
Immediate Management of delirium (2 hours from diagnosis of delirium)
•Test the delirium care bundle within local context for usability
•Test the delirium care bundle to achieve compliance and reliability
•Reduce the time for implementation of care bundle
•Create a culture that supports family and carer involvement in care
•Avoid inappropriate inter and intra ward transfers
•Link to Scottish Delirium Association Pathway (or local pathway) for further
management
•Develop an infrastructure to support local testing of the delirium bundle using
improvement approaches
•Develop educational resource to support identification and management of delirium
•Align work with other relevant work streams including wider older peoplels
improvement work, person centred health and care, dementia strategy, Scottish
Delirium Association Pathway and NHS Education for Scotland educational resources
•Optimise opportunities for spread
•Optimise opportunities to learn from and share good practice
Measures and Data Collection - Delirium
Aim: improve the identification and immediate management of delirium to
achieve 95% compliance with all elements of the care bundle
Core Measures
Screening for delirium (using 4AT or locally agreed tool)
Compliance with individual elements of the delirium bundle
Compliance with overall elements of the bundle
Reporting
enter data on excel spreadsheet - run charts
automatically generated and populate monthly report
– add in challenges and highlights
Send monthly report – last Friday of every month
Learning from the Experience of Patients, Families/Carers and Staff
•Interviews with patients, families and carers
•Focus Group with staff
•Digital Story
•Learning about Experience Cards