Improving Delirium Screening during Frailty Admissions: A Quality Improvement Initiative Utilising a Dedicated 4AT Proforma

Introduction

Delirium is a common clinical syndrome in older patients that significantly worsens hospital and long-term health outcomes. On-admission screening using the 4 A's Test (4AT) tool is recommended by NICE clinical guidelines. This quality improvement (QI) project evaluated and ensured accurate diagnostic coding while increasing documented delirium screening rates on admission at the Royal United Hospital, Bath.

Methods

A retrospective data review compared two-week patient cohorts from the frailty admissions team pre- and post-intervention. The baseline cycle (Cycle 1) evaluated admissions prior to integrating the 4AT into the electronic frailty admission proforma. The intervention (Cycle 2) introduced a modified electronic frailty proforma featuring explicit, written prompts to complete the 4AT screening. Documented assessment rates and subsequent delirium coding rates were analysed.

Results

Despite cohort expansion between Cycle 1 and Cycle 2 (n=235 vs n=310), documented 4AT screening rose from 26.8% (n=63) to 75.8% (n=235), a 49% absolute improvement. In Cycle 2, patients were 2.83 times more likely to have the 4AT documented (RR=2.83, p<0.05) with a 67% relative reduction in non-documentation. Population-wide, documented 4AT scores ≥4, indicating possible delirium, rose from 4.3% (n=10) to 23.2% (n=72), an 18.9% absolute increase in proactive detection (p<0.05). Correspondingly, undocumented patients ultimately coded with delirium dropped from 11.1% (n=26) to 3.5% (n=11), a 7.6% absolute reduction in missed cases (p<0.05).

Conclusion

Integrating explicit electronic written prompts within a dedicated frailty proforma substantially improved 4AT screening compliance, driving a statistically significant improvement in proactive delirium detection. This systematic approach effectively improved overall screening, further evidenced by the marked reduction in patients leaving the admissions process with undocumented delirium. Early identification and documentation of delirium enable earlier management of delirium and instigation of delirium pathways.