Improving Delirium Following Stroke

Introduction

Delirium affects approximately 25% of patients following stroke and may prolong hospital admission, hinder rehabilitation progress and increase morbidity. To support early delirium recognition and optimise patient outcomes, the National Clinical Guideline for Stroke for the United Kingdom and Ireland (2023) recommends early and repeated cognitive screening using a validated tool, for example the 4AT. We audited compliance with 4AT delirium screening and repeat assessment for stroke inpatients at Northumbria Healthcare NHS Foundation Trust. 

Methods

Patients discharged from two stroke wards between 06/03/2023 and 17/04/2023 with ICD-10 stroke diagnoses (I61, I62, I64) were included. Delirium screening data were extracted from patient records and analysed using descriptive statistics. Following Cycle 1, recommendations to improve 4AT compliance, including incorporating 4AT review into multidisciplinary team meetings, were implemented. Cycle 2 evaluated changes in compliance by repeating the audit in the same wards over the same period in 2025. 

Results

Cycle 1 (n=16) found that 87.5% (14/16) of patients received at least one documented 4AT assessment. Compliance increased to 89.2% (58/65) in Cycle 2, with all initial delirium screenings completed within 48 hours of admission. Repeat screening improved from 0% to 82.8% (48/58). Notably, 79.3% (46/58) of screened patients scored >0, highlighting high delirium prevalence and reinforcing the importance of routine screening.  No differences were observed between the two wards.  

Conclusion

This project demonstrates local compliance with national stroke guidelines for delirium screening, with improvement between cycles suggesting minor improvement following intervention. Opportunities remain to increase consistency in reassessment, to improve ongoing monitoring of fluctuating cognition. Recommendations include targeted staff education around the importance of repeat 4AT assessments and electronic record prompts for patients with 4AT scores >0 to encourage reassessment. By strengthening early and repeated delirium screening practices, we can support timely delirium recognition, better informed rehabilitation planning, and improved patient outcomes.