evidence & practice / mental health | PEER-REVIEWED |

Improving the identification of patients

with delirium using the 4AT assessment
Amelia Bearn, William Lea, Jennie Kusznir

Citation Abstract
Bearn A, Lea W, Kusznir J (2018) Delirium is a common neuropsychiatric disorder that all those working with older people will have
Improving the identification encountered at some stage. Delirium is often poorly identified in hospital settings and therefore
of patients with delirium not optimally managed. After data collection on the acute medical unit in an acute hospital trust
using the 4AT assessment. in the UK it was evident that patients with signs of delirium were not being formally assessed and
Nursing Older People. therefore not appropriately managed in many cases.
doi: 10.7748/nop.2018.e1060 A quality improvement project introduced the 4AT delirium assessment tool to try to ensure that
patients with delirium were being identified. The project team carried out several plan-do-study-
Peer review act cycles to bring about our changes, which included a 4AT assessment sticker for nursing staff
This article has been subject to complete and teaching for all healthcare staff. Through involvement of all members of the
to external double-blind multidisciplinary team and ongoing feedback and changes we were able to increase assessment
peer review and has been of delirium from 0% to 64%. There is ongoing work to be done to continue to improve delirium
checked for plagiarism using management, but by initially improving the assessment and identification of delirium we will make
automated software a difference to these patients’ outcomes.

Author details
Correspondence
[email protected] Amelia Bearn, foundation doctor, York Teaching Hospital NHS Foundation Trust, York, England;
William Lea, registrar, York Teaching Hospital NHS Foundation Trust, York, England; Jennie Kusznir,
Conflict of interest foundation doctor, York Teaching Hospital NHS Foundation Trust, York, England
None declared
Keywords
Acknowledgements delirium, mental health, older people
The authors would like to thank
Angela Keenan for designing the
delirium documentation, and the
acute medical unit and AMB staff DELIRIUM IS defined by the American has a poorer prognosis (Avelino‑Silva et al
Psychiatric Association (APA) (2013) as 2018). Staff may be more aware of patients
Accepted a disturbance in attention and awareness with hyperactive delirium because they
29 August 2018 that develops over a short period of time, often display distressed behaviour and
accompanied by a change in cognition require additional care. However, hypoactive
Published online which fluctuates, and is a result of a medical delirium has been shown to be more common
November 2018 condition. It may present in many ways. yet under-recognised (Schreier 2010,
Often, patients present as more confused than Morandi et al 2017).
usual, disorientated and unable to focus. They
may have rambling or incoherent speech, Risk factors
a labile mood, being withdrawn or agitated A number of predisposing and precipitating
or switching between the two. They may factors put patients at higher risk of delirium
hallucinate or have altered perceptions of (Box 2) (Inouye 2018, Solà-Miravete et al
their environment. Often relatives may say 2018). Many of these factors are also indicators
that a patient ‘is not their normal self’ (APA of acute illness and deterioration. Therefore,
2013). Delirium is diagnosed when the features these patients should not be dismissed due
outlined in Box 1 are present. to distressed behaviour or inability to give
There are two subtypes of delirium: a history, as they may need immediate medical
hyperactive and hypoactive, or people may intervention (Hsieh et al 2015).
present with a mixed picture. Hyperactive
Permission delirium is characterised by increased motor Effect of delirium
To reuse this article or activity, agitation, restlessness, hallucinations Delirium is often encountered by those working
for information about
reprints and permissions, and inappropriate behaviour. Hypoactive with older people and affects 10-30% of older
please contact delirium is characterised by reduced motor patients admitted to hospital (Siddiqi et al
[email protected] activity, lethargy, drowsiness, withdrawal and 2006), with overall occurrence in hospitals

18 / December 2018 / volume 30 number 7 nursingolderpeople.com

| PEER-REVIEWED |

of 18-35% (Inouye et al 2014a). Despite its Assessment

high incidence, delirium is not recognised in up All patients admitted to hospital with Implications
to 72% of cases in acute settings (Collins et al a new or worsened confusion should be for practice
2010). Delirium can contribute to poorer assessed for signs of delirium and a cause
patient outcomes by increasing the risk of identified. Methods for the assessment of ●● All staff should be
complications, including aspiration, pressure delirium include the 4AT (MacLullich 2014), aware of how delirium
ulcers, pulmonary emboli and poor oral intake the short confusion assessment method can present and who
(Fong et al 2009). Delirium can result in higher (Inouye et al 1990) or the single question in is at risk. Regular
mortality, institutionalisation, longer hospital delirium (Sands et al 2010). teaching and education
stays and dementia (Witlox et al 2010). Studies have shown that the 4AT is a highly can be made available
sensitive and specific method of diagnosing ●● Strategies can be
Prevention delirium (Bellelli et al 2014, De et al 2017). put in place to
Studies suggest that delirium may be The 4AT aims to assess a patient’s underlying prevent delirium
preventable in up to a third of cases, therefore level of cognitive impairment along with level
identifying those at risk is vital (British of alertness and change in mental status. First, ●● Nurses can assess
Geriatrics Society and Royal College of the assessor should observe the patient for patients for delirium
Physicians 2006, Inouye 2018). Strategies their level of alertness, then ask brief questions using the 4AT
for prevention of delirium include ensuring to determine their cognition and attention, and ●● Assessing all older
good nutrition and hydration, maintaining finally the assessor should indicate if there is patients for delirium
adequate oxygenation, analgesia, mobilisation, apparent fluctuation in symptoms (Figure 1 can increase diagnosis
encouraging social contact with family and shows specific questions and scoring). A score
friends, promoting a healthy sleep-wake cycle of 0 suggests that cognitive impairment and ●● Delirium should
and ensuring the environment aids orientation delirium are unlikely, a score of 1-3 suggests be managed
(Asadi et al 2018). Many patients, however, underlying cognitive impairment and a score promptly using
will already have signs of delirium at admission of 4 or more suggests delirium is likely supportive measures
and for these patients the first step in providing (MacLullich 2014). ●● A delirium pathway
optimal care is recognition and diagnosis. The 4AT can be used on admission to may aid patient
determine a baseline measure of a patient’s management in a
Box 1. Features of delirium required mental status and then patients can be ward environment
for diagnosis reassessed throughout admission if there are
any concerns. The benefit of the 4AT over
»»Disturbed consciousness with reduced ability to focus, other delirium assessment methods is that
sustain or shift attention not only is it quick, simple and easy to use,
»»Change in cognition, such as memory deficit, but it also considers those patients who are
disorientation and language disturbance, or untestable and assesses cognitive function
development of perceptual disturbance that is not better (MacLullich 2014, Shenkin et al 2018). This
accounted for by a pre-existing or evolving dementia means that the 4AT can be used for patients
»» Fluctuating disturbance developing over hours or days
»» Evidence that disturbance is caused by the direct
who may be very drowsy due to a hypoactive
delirium and for those who may have an
physiological consequence of a general medical
condition, substance intoxication or withdrawal underlying dementia.
(American Psychiatric Association 2013)
Management
After diagnosis of delirium all members of
Box 2. Risk factors for delirium the multidisciplinary team (MDT) should

»»Older age (over 65 years) Table 1. Methods to help manage symptoms of delirium
»»Severe illness
»»Dementia Environment Nursing and multidisciplinary team care Medication
»»Physical frailty
»»Infection »»Appropriate lighting »»Continuity of care »»Regular analgesia
»»Dehydration or malnutrition »»Re-orientation »»Early mobilisation »»Oxygen if hypoxic
»»Sensory impairment »»Clock or calendar visible »»Promote good sleep »»Laxatives if risk of
»»Polypharmacy »»Family/carer input »»Food and fluid intake constipation
»»Recent surgery »»Reassure patient of »»Explanation of activities/procedures »»Full medication review
»»Alcohol excess safety »»Monitoring for signs of infection »»Sedation only if
»»High comorbidity »»Avoid ward/bay »»Avoid unnecessary tasks patient at risk to self
»»Catheterisation transfers »»Falls prevention or others
»»Pain (acute or chronic)
(National Institute for Health and Care Excellence 2010, Schreier 2010, Healthcare improvement Scotland 2014)
(Solà-Miravete et al 2018)

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evidence & practice / mental health | PEER-REVIEWED |

ensure that actions are taken to appropriately A medication review is vital for all patients
manage patients. diagnosed with delirium and particular
Delirium always has an underlying medical attention paid to any newly started medications
cause, therefore the next steps should be or psychotropic drugs (Grover and Avasthi
investigation of this cause (Burns et al 2004). 2018). As delirium is usually multifactorial
Patients may or may not be able to give in nature any possible underlying causes
a thorough history of events, therefore it is that come to light through assessment and
important to gather information from as many investigation should be treated immediately.
sources as possible including family, friends or Supportive measures that should be put in place
carers (Grover and Avasthi 2018). A doctor while medical problems are being resolved
should examine the patient and determine are outlined in Table 1 (National Institute for
what investigations are most appropriate. Health and Care Excellence (NICE) 2010,
This should include monitoring of vital signs, Schreier 2010, Healthcare Improvement
electrocardiogram and blood and urine testing Scotland 2014). As delirium can be an indicator
as a minimum. Some patients may require of poor physical condition and prognosis all
further investigations such as imaging, stool staff should be aware of possible deterioration
or sputum cultures if indicated (Healthcare and ensure patients are monitored closely and
Improvement Scotland 2014). treated in a timely manner (Hsieh et al 2015).
Sedation should only be used if a patient
Figure 1. 4AT assessment sticker is a risk to themselves or others and is
a last resort if supportive and de-escalation
4AT Delirium assessment tool (65 years and over) measures are insufficient to manage distressed
Has your patient been more confused, sleepy or drowsy? Place this sticker in behaviour. As recommended in the NICE
the notes and complete to assess for delirium. (2010) guideline, haloperidol or olanzapine
are the first-line drugs of choice and should
1
Circle score for
Alertness each section be given in small doses for short-term use
only (Jain et al 2017). Antipsychotics are not
Normal (fully alert, but not agitated) 0
suitable for people with Parkinson’s disease
Mild sleepiness for <10 seconds after waking, then normal 0 or Lewy body dementia, and all patients
Clearly abnormal 4 must have an electrocardiogram before
these drugs are prescribed. Sedation must
AMT4 Ask your patient the following: age, date of birth,
2 name of hospital/building, current year
be used with caution and avoided as much
as possible. Patients usually do not require
No mistakes 0 sedation but sensitive nursing and medical
1 mistake 1 care to ensure precipitating factors are
eliminated and that they are made to feel safe
2 or more mistakes or untestable 2 (Inouye et al 2014a, 2014b).
Attention Ask your patient to list the months of the year
3 backwards Aims of project
The aim of this project was to improve the
7 months or more correctly 0 identification of delirium and specifically
Starts, but scores <7 months/refuses to start 1 that 100% of newly confused patients over
the age of 65 admitted to the acute medical
Untestable (cannot start because unwell, drowsy) 2 unit (AMU) should have a 4AT assessment.
4 Acute change or fluctuating course Successful completion of a 4AT assessment
would then increase identification and
Evidence of significant change or fluctuation in
alertness, cognition, other mental function arising diagnosis of delirium. The secondary aim of
over the last 2 weeks and still evident in last 24 hours the project was to improve assessment and
management of delirium in the acute ward
No 0 environment after diagnosis.
Yes 4 ‘New confusion’ is defined as: a patient
who is not known to have this degree of
confusion previously who now presents with
4 or above – possible delirium – Total disorientation and signs of increased confusion,
use the Delirium pathway score
or collateral history of increased confusion
1–3 – possible cognitive impairment Adapted from over the preceding week which is not normal
0 – delirium or severe cognitive impairment unlikely (but MacLullich A (2014).
See full delirium
for them. This includes patients who have
delirium still possible if 4 information incomplete a known dementia or cognitive impairment,
guideline on intranet.
but have an acute worsening of mental status.

20 / December 2018 / volume 30 number 7 nursingolderpeople.com

| PEER-REVIEWED |

Methods to give ongoing feedback and suggestions Online archive

The Model for Improvement (Langley et al throughout the PDSA cycles. The team also For related information,
2009) and the plan‑do‑study‑act (PDSA) worked with directorate management, matrons visit nursingolderpeople.
com and search using
(Deming 1994) method of testing change were and allied health professionals (AHPs) to ensure the keywords
used. PDSA is a frequently used tool in quality they were aware of the project and to obtain
improvement and supports repeat cycles of organisational support through the formation
testing and measuring outcomes to allow for of a delirium operational group. Four change
further planning and interventions. cycles were undertaken.
Implementing a quality improvement project
requires a clear aim, objectives and dynamic PDSA cycle 1
changes. A need for better recognition of After collecting baseline data we then planned
delirium in patients over the age of 65 was our initial intervention. This involved
identified and the team chose to begin the designing and producing a sticker with the
project on the AMU. This would allow us to 4AT assessment on it, which nurses could
review medical patients who had just been use to assess patients they felt had a new
admitted to hospital. confusion (see Figure 1 for example sticker).
An appropriate measure that will provide We discussed the new stickers with ward sisters
feedback on whether changes are resulting and asked them to mention them at their daily
in improvement is important. The measures handovers to ensure all team members were
for this project were the percentage of newly aware of their use. The stickers were available
confused patients who had a 4AT assessment on the ward for staff to use as they felt
carried out (measure 1), as well as the overall appropriate. It was left to the nurses’ discretion
rate of coded delirium diagnoses in an acute to identify patients who required assessment.
hospital setting in the UK (measure 2).
Measure 1 was recorded one afternoon PDSA cycle 2
every week while carrying out PDSA cycles, We educated all staff on the AMU about
and measure 2 was recorded monthly using delirium and the new assessment tool to ensure
hospital coding data obtained from the all were aware of the changes and could give
Comparative Health Knowledge System. feedback. Members of the project team were
To gather information about practice and available on the ward multiple times a week to
provide a baseline of confusion assessment, allow questions to be asked and to help inform
we collected data on a weekly basis for staff further when necessary. We recognised the
14 weeks before any intervention was made. importance of the MDT and wanted to involve
The medical notes of all patients over the all nurses, healthcare assistants and doctors in
age of 65 admitted to the AMU at that time the project. Each morning on the AMU there
were reviewed to provide weekly snapshots is a daily safety brief. During this brief we
of data. We looked for any documented reminded staff about the project and use of
evidence that the patient had a new confusion
(reviewing ambulance documentation through Figure 2. Delirium teaching handouts
to consultant review after admission) and
recorded who recognised this: nurses, junior Delirium improvement project
doctors or consultants. We then looked at
What is delirium?
whether any formal assessment of delirium had
taken place for these patients. This baseline 3 Cs: change in:
data enabled us to see what was already
happening when these patients were admitted
Consciousness
and how we might best tackle the problem. Cognition
Healthcare is a complex environment and
getting to grips with the systems and processes Concentration
or ‘what really happens’ involves speaking Acute and fluctuating
to the right people. Before implementing any
Who? Anyone! Especially >65, dementia, frail,
changes, we recognised that we would need comorbidities and surgery
to involve all interested parties. A stakeholder
analysis (NHS Institute for Innovation and Why? Infection, dehydration, malnutrition,
medications and pain
Improvement 2010) was carried out to identify
What can we do? 4AT and delirium pathway
who needed to be involved in the project. The
project team included junior and senior doctors,
Remind, Reorientate, Rehydrate, Reassure
nurses, an old age psychiatrist and a liaison
mental health team nurse. This team was able Beware! Falls, food, sores and sedation

nursingolderpeople.com volume 30 number 7 / December 2018 / 21

evidence & practice / mental health | PEER-REVIEWED |

the 4AT to ensure that all were aware of how to carry out the assessment for all patients
to use the stickers and which patients it was over 65 years old. The admission booklet is
appropriate to use the assessment tool for. a multidisciplinary pathway completed by
nursing, medical and AHP staff during the
PDSA cycle 3 first few days of a patient’s hospital admission.
Mini teaching sessions on delirium were The booklet contains a range of assessments
delivered on the ward to small groups of staff. and spaces for documentation such as initial
We discussed what delirium is, predisposing nursing and medical clerking and review.
and precipitating factors, recognition, It was vital throughout the project that we
assessment, management and possible identified any areas of concern or problems. We
complications. Figure 2 shows the handout gathered regular feedback from staff on use of
that was given to staff members after the the 4AT stickers and clarified any queries. The
teaching to help them to remember what AMU has many healthcare staff, with some
was discussed. All members of staff were working less frequently, and with regular doctor
encouraged to share their concerns about changeovers. We needed to ensure that new
new confusion in patients and this enabled staff could be educated about our project. We
discussion about when to consider delirium as used posters and attended the ward to ensure
a possibility and the use of the 4AT assessment. that there was continuation in staff awareness.
Nursing staff produced a fishbone diagram We produced a figure from our data which
to identify factors preventing improvement is a graph displaying measure 1 (percentage of
(Figure 3). A fishbone diagram enables analysis newly confused patients who received a 4AT
of barriers to a project and highlights specific assessment) against time (Perla et al 2011). The
areas for improvement (Tague 2005). The figure was shared with staff on the AMU so
issues identified were then addressed through that progress could be followed in a dynamic
further PDSA cycles. way and updates given to staff about progress.
After introduction of the 4AT assessment
PDSA cycle 4 it became clear that the team must also know
Based on the findings of the fishbone diagram how to manage these patients appropriately.
exercise, the 4AT sticker was placed in every Through reviewing relevant literature and
admission booklet to prompt nursing staff publications such as the NICE (2010)

Figure 3. Fishbone diagram

Method Nurses No 'prompts' – it could be part of the 'routine'

Need to include delirium 4 hourly checklist on nursing assessments with
Put assessment checks on nursing rounds for Time constraints observations (blood pressure and pulse etc)
tool in every healthcare assistants/nurses
clerking book Nurses not aware of Not aware of when to use it eg 'on
Not clear which part of admission', every 2-4 hours, or if high risk?
how to use the tool
Need delirium posters the pathway is for nurses
(include delirium in
to prompt action on wards mandatory training) Bank staff unfamiliar with it
'Think Delirium'
Laziness?
Have an algorithm for
treatment to prompt Staff forget
action like 'sepsis 6':
D – Dehydration
E – ECG Not completing
L – Laxatives? delirium assessment
I – In pain tool (4AT)
R – Retention
I – Infection
U – U+Es/bloods Difficult to assess if Difficult to know the ‘baseline’
M – Medication hypoactive delirium of a patient. Could include
(s) – Sepsis+Blood Sugar
Put pathway on in nurse handover (SBAR),
Does the medical particularly if patient has
computer team request the dementia and usually confused
Have pathway + delirium screen?
assessment/tick boxes Have agitation score?
separate (lots of words (Too complicated?)
are off-putting) Not clear which bits
medical team or
nurses use Medical team to document
on pathway if patient has
Paperwork Multidisciplinary team delirium or if confusion is
and patients progression of dementia

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guideline and the Triggers, Investigate, Manage points fall either above or below the median
and Engage (TIME) bundle (Healthcare on a figure, there is said to be a ‘shift’ change
Improvement Scotland 2014), we produced (Perla et al 2011). In this case there was
a pathway to aid management (Figure 4a and a shift increase in delirium diagnosis. This
4b). This pathway was developed and changed shift improvement equates to approximately
over many weeks with nursing staff on the 25 more patients receiving a diagnosis of
ward ensuring the pathway was practical to delirium per month.
use. They produced a useful acronym to help
staff remember the supportive measures that Table 2. Data from weekly notes review in the acute medical unit
can be implemented, which was incorporated
into the pathway. It was also felt useful to Date Total number of Number of Number of confused % of confused
have a checklist to ensure that all appropriate patients over 65 confused patients patients with 4AT patients with 4AT
investigations had been requested and over 65 assessment assessment
assessments made by the medical team. Junior
13/10/17 47 12 0 0
doctors raised concerns about the use of
sedation in this patient group. Therefore we 2/11/17 49 13 0 0
ensured that it was made clear on the pathway
when sedation would be appropriate and the 9/11/17 33 6 0 0
drug and dose of choice in the trust if required.
16/11/17 26 5 0 0
Results
23/11/17 39 11 0 0
We collected baseline data for 14 weeks before
making any changes, then continued with 30/11/17 40 10 0 0
weekly data collection after this (Table 2).
Our baseline data identified that there was 7/12/17 36 4 0 0
a median of 25% of patients over 65 years
who were found to have a new confusion 15/12/17 41 6 0 0
when admitted to the AMU. It was important
21/12/17 40 8 0 0
that we knew how this new confusion was
being recognised. Through reviewing the 28/12/17 49 15 0 0
medical notes, we found that nursing staff
identified and documented new confusion 4/1/18 36 9 0 0
in 65% of cases. Doctors identified and
documented confusion in 26% of cases. 11/1/18 48 15 0 0
Through further review of the medical notes,
20/1/18 32 5 0 0
we ascertained that of all newly confused
patients, none were having a validated delirium 25/1/18 40 15 0 0
assessment carried out.
After our initial PDSA cycle, and the 1/2/18 35 13 6 46
introduction of the 4AT assessment, the
median number of confused patients having 8/2/18 49 9 4 44
a 4AT assessment improved to 32%. As
outlined in our methods we continued to carry 15/2/18 28 6 3 50
out PDSA cycles and implement changes. 22/2/18 38 8 1 13
After four PDSA cycles the median number
of patients receiving a 4AT assessment rose 1/3/18 27 4 1 25
to 64% (Figure 5). Figure 5 demonstrates
a significant improvement in the number 8/3/18 34 9 3 33
of patients receiving a 4AT assessment
(Perla et al 2011). 15/3/18 28 7 2 29
Figure 6 illustrates the number of diagnoses 22/3/18 27 8 3 38
of delirium coded throughout the hospital
per month. Before implementing our changes 29/3/18 29 4 0 0
the baseline median number of patients with
a coded delirium diagnosis was 70 per month. 5/4/18 28 7 6 86
During the improvement project phase there
was an increase in coding for delirium, with 12/4/18 35 7 5 71
all points from April 2017 falling above the 19/4/18 35 8 4 50
baseline median. When six or more consecutive

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evidence & practice / mental health | PEER-REVIEWED |

Discussion and lessons time. One vital lesson was that placing the 4AT
Our multifaceted approach has resulted in assessment into all admission documentation
a significant increase in the assessment and for all patients was a prompt for staff, which
identification of patients with delirium. resulted in an increase in completion rates.
Engaging with front-line staff we have Involving members of the MDT who
introduced the 4AT assessment, along with have patient contact was essential and we
educational activities provided by doctors and achieved this through updates at morning
mental health nurse specialists. Using PDSA safety briefs and by informal mini teaching
cycles we have developed our interventions over sessions on the AMU.

Figure 4a. Delirium pathway leaflet, facing page

This patient has delirium

Delirium pathway
for patients over 65 years
»» If your patient is more confused than
usual initiate this pathway
»» Place this in the patient’s notes and
highlight it to the nurse and doctor

Date: Time: Ward: Affix patient label

Risk Assessment Management

This patient seems more Identify and treat the
The following will put confused than usual underlying cause
your patient at higher The following strategies may
Family carers think this
risk of delirium be used to manage delirium:
patient is more confused
(Tick all Not for alcohol
intoxication/
Document the D Disorientation and dehydration
applicable) 4AT score: »» Reorientate (time/place)
withdrawal »» Involve family/carers
See full Tick when completed:
»» Avoid ward/bay transfers
guideline Nurses' tasks: »» Oral/parenteral fluid
Age (>65 years) NEWS score (think sepsis) E Environment
Severe illness Blood glucose »» Calm/quiet/comfortable
Dementia ECG
L Lighting
»» Day/night orientation
Physical frailty Doctors' tasks:
»» Use of clocks
Infection Medication review
I In pain?
»» Assess for non-verbal signs
Dehydration Pain review »» Consider regular analgesia
Sensory/impairment Assess for urinary retention R Retention of stool or urine
»» Encourage toileting
Polypharmacy Assess for constipation »» Laxatives if necessary
Renal/liver failure Assess hydration I Infection
»» Look for and treat (eg UTI/LRTI)
Psychoactive meds Bloods (FBC, U+E, Ca, LFT, »» Avoid catheterisation
Acute/chronic pain
CRP, Mg and Glucose) U U+Es and bloods
Assess for infection
»» Monitor bloods as necessary
Catheterisation
Review ECG
M Medications
»» Review meds

Delirium is not a diagnosis and you must

S Sensory impairment

determine the underlying cause

»» Visual and hearing aids
Probable cause of delirium: »» Family support + information
»» Avoid sleep disturbance
»» Monitor O2 sats Please give
and blood pressure family carers
»» Encourage a copy of
mobility/exercise the delirium
Document delirium in your differential and on CPD »» Optimise nutrition information
leaflet

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| PEER-REVIEWED |

The advantage of members of the project several explanations for this variability. It may
team being front-line staff involved in the be that new or different staff working on that
changes has meant that they have a real day were not aware of the delirium assessment
understanding of what is required and how stickers and therefore they were not used as
to achieve it. They can also provide a direct often. It may correlate with very busy times
route of feedback for other members of on the ward when staff did not feel they had
the project team. time to complete the assessments. As the
During PDSA cycle 2 we started to discuss delirium assessment becomes an integral and
the delirium project at morning safety briefs well-known part of patient care on the wards
and during PDSA cycle 3 we began mini we may see less dips and more of an ongoing
teaching sessions for staff; we did not assess upward trend in the number of patients having
the effectiveness of these activities formally a 4AT assessment.
but continued to monitor our measures as We have used delirium diagnosis coded at
already described. Formal assessment of these discharge (whole hospital) as a measure for
activities could determine their effectiveness this project but are aware that a more accurate
and possible improvements. measure would have been to look at diagnosis
Although an improvement in assessment of patients from AMU alone. Diagnoses are
of delirium is clearly identified by an overall not coded until discharge and diagnoses made
improvement in the median, there were ups for inpatients are often not added to the
and downs over the weeks. There could be electronic record until they have left the AMU.

Figure 4b. Delirium pathway leaflet, reverse page with local contact removed

Delirium pathway

Sedation may be used with caution in certain situations

»» To carry out essential investigations or treatment
»» If the patient is distressed or considered a risk to themselves or others, and verbal and non-verbal de-escalation
techniques are ineffective or inappropriate

Haloperidol should not be used in Parkinson's disease or Lewy body dementia

and used under specialist advice in cases of seizures or where the QTc is
prolonged (>470 ms)

First line
Oral Intramuscular
Haloperidol (peak effect 4-6 hours) Haloperidol (peak effect 20-40 minutes)
>65 years: 0.5 mg, 2 hourly Allow >65 years: 0.5mg, 2 hourly
No more than 2mg in 24-hour period 20–30 minutes No more than 2mg in 24-hour period
to evaluate
response

Review and optimise management

If patient fails to respond or haloperidol is contraindicated –
Seek senior advice

If patient is not settling and/or is requiring multiple doses of sedation

discuss with senior/medical consultant + psychiatrist on call

If you are struggling to manage a patient with delirium you should contact your
Help seniors for advice. The following are also available:

nursingolderpeople.com volume 30 number 7 / December 2018 / 25

evidence & practice / mental health | PEER-REVIEWED |

Write for us The main reason for using whole hospital Another limitation of the project was the
For information about coding rate was logistical and improvement small sample size. Although we could still see
writing for RCNi journals, projects like this one must be achievable. the trend over time, as the number of patients
contact writeforus@rcni.
com No other improvement work on delirium was small this can have a significant effect in
assessment and diagnosis was occurring in the percentages and may show large variation.
For author guidelines, organisation during the project period, and our By using percentages, however, this meant
go to rcni.com/writeforus results demonstrate a significant and sustained that we could compare data over many weeks
improvement. The potential limitation of despite varying numbers of patients on the
this approach is noted, but we feel that the ward. It may be interesting to carry out data
increase in delirium diagnosis demonstrated collection on a wider scale in the future, either
is likely to be due, in significant part, to this throughout the hospital or in a larger trust, to
improvement project. see if similar results are found.

Figure 5. Percentage of patients with new or worsening confusion who received a 4AT assessment on the
acute medical unit

Baseline measurement Improvement project

90

80
Percentage of patients assessed with 4AT

70

60

50

40

30

20

10
Median
0
13 2 9 16 23 30 7 15 21 28 4 11 20 25 1 8 15 22 1 8 15 22 29 5 12 19 26
Oct Nov Nov Nov Nov Nov Dec Dec Dec Dec Jan Jan Jan Jan Feb Feb Feb Feb Mar Mar Mar Mar Mar Apr Apr Apr Apr

PDSA = plan-do-study-act cycle

PDSA 4
PDSA 3
PDSA 2
PDSA 1

Figure 6. Number of diagnoses of delirium coded throughout the hospital per month

Baseline measurement Improvement project

120

100
Number of delirium diagnoses (per month)

80

Median
60
Shift
improvement
40

20

0
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
16 16 16 16 16 16 16 16 16 16 16 16 17 17 17 17 17 17 17 17 17 17 17 17

Data Source: CHKS iCompare

26 / December 2018 / volume 30 number 7 nursingolderpeople.com

| PEER-REVIEWED |

An electronic patient record is used in 4AT stickers. We showed through our initial FURTHER NURSING
our organisation with the ability to create data collection that nursing staff are the most OLDER PEOPLE
RESOURCES
automatic electronic prompts. The system likely members of the MDT who recognise
Assessment and
already has prompts to assess patients for acute that patients are more confused than usual management of older
kidney injury, sepsis, venous thromboembolism and therefore are best placed to assess these patients with delirium in
risk and dementia. We plan to integrate an patients for delirium. Through empowering acute settings (2018)
electronic assessment for delirium 4AT and nurses to assess patients for delirium the rcni.com/delirium-
hope that this will continue to improve its diagnosis of delirium was improved. This assessment
identification. initial step of identification is crucial in Could it be delirium? (2018)
rcni.com/delirium-signs
Although we have collected data on the ensuring patients get the prompt management
Nursing care for
identification of delirium and completion of they require and to prevent further people with delirium
the 4AT assessment, we have not yet examined deterioration in their mental and physical superimposed on
the subsequent management of delirium after state. We have focused on delirium at the point dementia (2017)
introduction of the delirium pathway. The of admission, but identifying those at risk of rcni.com/delirium-
aim would be to improve the management delirium and undertaking a baseline assessment dementia
of delirium and achieve a reduction in post- using 4AT, as well as monitoring for the
admission incidence, complications, length of development of delirium after admission are
stay, morbidity and mortality. These are areas important (NICE 2014). The involvement of
for future work in our organisation that we nursing staff in producing a delirium pathway
can formally assess. helped to have a method of ensuring patients
were being thoroughly assessed and supportive
Conclusion measures being put in place.
Delirium is a condition that all staff working Recognising and managing delirium in
with older people will encounter. It can have older patients is everyone’s responsibility.
detrimental effects on patients if it is not By working together as a team, giving all
identified and managed promptly. Overall members the tools to diagnose delirium and
this project was a success in improving the the strategies to manage it, patients will receive
assessment of delirium on the AMU using the the best care possible.

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