.
University of Dundee
College of Medicine, Nursing & Dentistry
Recognising Delirium in an Acute Medical Setting
Jane Balmer & Kirsty McNeil
University of Dundee Medical School
Introduction
Results
Delirium is a debilitating condition that increases
morbidity, mortality and doubles the length of time that
patients stay in hospital. Unfortunately it is often missed
in patients leading to it’s screening and management
becoming a national priority.
In Tayside, a team collected data that reflected the
national statistics of a high prevalence but poor
recognition and management of delirium in acute care.
In the Acute Medical Unit we made a number of changes
that led to very positive results.
Aims
We predicted that patients with a 4AT score ≥4, suggestive
of delirium, were being poorly investigated and diagnosed
and our data reflected this showing only 14.3% of patients
being followed up.
In accordance with national aims we aimed to increase
the identification, diagnosis and management of
patients brought into the acute care setting, namely
the Acute Medical Unit in Ninewells, to 95% by July
2013.
After carrying out the feedback and education sessions we
seen 2 peaks of 100% follow up. However, these were short
lived and only on the quietest days of patient admittance
suggesting that we had missed another factor.
We planned to do this by increasing the awareness of
delirium among staff members and to put a system in
place which would make it harder for human factors to
affect the process.
Being in such a busy setting, with an average of 56 patients
coming through a day, pressure is intense on staff to treat
patients quickly. On follow up nurses responded saying they
either didn’t have access to or were unsure with what to do
with the results of 4AT tests if they were carried out.
Method
We carried out our own baseline data collection measuring
the prevalence, recognition and management of delirium,
using data collection tools we created ourselves over the
course of several PDSA cycles. The data was collected over
a 24hour period using patients that fitted the criteria. Our
inclusion criteria were patients ≥75 who had not been
discharged or transferred to another hospital. We excluded
patients referred in from their GP with a diagnosis of
delirium already made. We then gave feedback of our
findings at doctor’s safety briefings.
We carried out education sessions with nurses and other
members of the MDT team to introduce and train them on
the 4AT tool and it’s relevance in delirium.
Finally, we carried out 2 tests of change. The first was on
the use of the 4AT tool as a screening tool for delirium on
admission for over 75’s. The second tested the use of this
coupled with the Tayside Delirium Pathway to both
diagnose and manage patients with delirium.
Senior nursing staff, working closely with us, brought in 4AT
screening as part of initial functional assessment for those
over 75 or confused. The 4AT was added to the assessment
pack used by all members of the medical team leading to
100% of patients with a 4AT score ≥4 being fully investigated
and managed. This was sustained even on busier days with
no disruption to staff or other patients evident.
Conclusion
By targeting all the members of the health care team with
feedback and education, we were able to improve delirium
screening and management through a multidisciplinary
approach.
The busy clinical setting, coupled with high staff and patient
turnovers, was challenging. However by making the
materials more accessible and part of an established well
used routine, we successfully removed some of the barriers
to correct identification, investigation and management of
patients with delirium.