Improving Early Delirium Recognition Through Structured 4AT Integration

Introduction: Delirium affects up to one in four older adults admitted to hospital and is associated with increased mortality, prolonged admission and long-term cognitive decline. Early recognition is recommended by NICE and international guidelines. The 4 ‘A’s Test (4AT) is a validated, rapid bedside screening tool widely used in acute settings. Despite this, timely completion in routine practice remains inconsistent. This quality improvement project aimed to improve compliance with 4AT completion within 24 hours of admission in patients aged ≥65 years.

Method: A retrospective audit was conducted across three acute hospitals within the Trust, reviewing admission documentation for all patients aged ≥65 years over a 24-hour period. Three audit cycles were completed using Plan–Do–Study–Act (PDSA) methodology. Cycle 1 established baseline compliance. Interventions implemented before Cycle 2 included a dedicated 4AT document, incorporation of 4AT into medical and surgical clerking proformas, and inclusion in the SBAR communication tool. Results were disseminated to geriatric consultants and multidisciplinary teams via Trust communications, and Cycle 3 assessed sustained improvement. The primary outcome was documented 4AT completion, with secondary analysis of completion within 24 hours.

Results: Baseline compliance was 10%. Following sequential PDSA cycles, overall 4AT documentation increased to 31%, representing a threefold improvement. However, adherence to the recommended standard of completion within 24 hours remained limited: 19% were completed within 24 hours and 11% after 24 hours. Interventions embedded within admission documentation appeared to drive greater improvement than passive dissemination alone.

Conclusion: Sequential PDSA cycles improved overall 4AT documentation, demonstrating that structural integration into admission workflows can positively influence practice. Nevertheless, timely screening within 24 hours remains below standard. Sustained multidisciplinary engagement and further workflow integration are required to optimize early delirium recognition and strengthen patient safety in older adults.