Abstract
Background: Delirium is a common clinical condition associated with increased morbidity and mortality, and prolonged hospital stay. Early detection is vital to improving management of the condition and improving outcomes.
Our aims: improve delirium detection using the 4AT screening tool as a validated approach, Improve delirium management across multiple domains using the PINCH ME approach; documented attempt at collateral history within 24 hours of recognition of delirium; obtain serological confusion screen in patients with recognised delirium. (100% each)
Methodology: Plan Do Study Act (PDSA) methodology was used to conduct this Quality Improvement (QI) project over 12 months. Data was obtained from paper and electronic records in the medical wards with regards to 'at risk patients' (i.e. over 65y, acutely unwell, background of cognitive impairment and/or acute fracture). The use of 4AT or alternative delirium screens from the emergency department (ED) and medical teams were noted. Assessment for pain, urinalysis, serological screens, bowel and nutrition review including MUST scores, medication reviews were looked for. Interventions included presentation and education at the medicine grand round, publishing a poster, and a PINCHME alert sticker for the medical notes to use at time of assessment. 2 PDSA cycles were completed and post sticker results obtained.
Results: Baseline data shows that collateral history was attempted for 70% patients - improved to 100% after sticker use. Use of validated screening test from 15% to 100% after sticker use. Nutrition assessment improved from 15% to 40%. Serological testing improved from 40% to 53%. 100% patients received a medication review after sticker use.
Conclusion: Introduction of PINCHME sticker serves as a prompt to ensure holistic management. Currently delirium management is clinician dependent as there is lack of formal delirium management pathway.Further plan includes involving nursing staff and 'delirium champions' to bring about a formal pathway for lasting change.
Comments
Thank you, excellent work. Did you apply stickers to the patient notes of all those >65 yrs? Is the 4AT integrated into the ED/medical clerking proforma- and if so, do you find it is completed correctly/at all?
Hello! Thank you very much.
At the time, the ED clerking had a separate dedicated sheet to fill the 4AT, the medical clerking had it integrated.
It would be filled more often by ED colleagues than medical.
Majority of our audience for the poster and teaching were the in patient team, which brought compliance up for correctly filling the 4AT.
We applied stickers to patients with documented confusion - either mentioned in the history, or found on examination.