A Structured Approach to Delirium Assessment in Older Patients Using the 4AT Tool​

Introduction

Delirium is a medical emergency characterized by a recent (within hours or days) changing or fluctuating course of confusion. It manifests through altered arousal, inattention, and disordered thinking. Delirium had significant short- and long-term adverse clinical outcomes including extended length of stay, increased inpatient complications, elevated all-cause mortality, and reduced survival rates.(1) In January 2023, the National Institute for Health and Care Excellence (NICE) revised its delirium guidelines, endorsing the 4AT as the preferred assessment tool for detecting delirium in general clinical settings.(2)

Objectives

To evaluate the compliance of the 4AT screening tool for delirium detection among eligible elderly patients.

Methodology

A retrospective audit was conducted in two phases at Barnsley Hospital to evaluate the use and compliance with 4AT delirium screening. The initial phase reviewed 98 patient records to establish a baseline for current screening practices. Following this, a second phase analysed 336 patient records after implementing targeted quality improvement measures. These measures included making the 4AT tool a mandatory component of AMU clerking documentation, introducing clear exclusion criteria, promoting consistent use of the tool by clerking staff, and disseminating audit results to emphasise the clinical importance of early delirium identification.

Results

Compliance with 4AT completion was observed to be lower in the Hot Take proforma compared to the AMU clerking proforma. Overall performance of 4AT screening showed marked improvement following the implementation of interventions after the first audit cycle, increasing from 31.36% to 74% over the review period.

Conclusion

The audit demonstrated an improvement in the use of the 4AT screening tool for delirium assessment following targeted interventions. However, the small sample size in the first cycle and underutilization among diagnosed patients indicate the need for continued efforts to optimize its usage. Ongoing education, reinforcement of guidelines, and regular audits may further enhance delirium detection and patient outcomes.