Improving frequency of 4AT scoring through micro teaching

Introduction

Delirium is a neuropsychiatric condition affecting over 1 in 4 hospitalised older adults. Regular assessment of delirium throughout admission leads to earlier diagnosis and management and may potentially improve outcomes.  The 4AT is a NICE recommended  tool to detect delirium.

Methods

Retrospective case review was undertaken for a cross-section of older adults (n= 90) admitted to an inpatient geriatric ward in a tertiary London hospital. We recorded whether 4AT was completed at 3 key time points; during clerking, post-take ward round and at any point during inpatient stay. A plan-do-study-act methodology was used and two key interventions were introduced sequentially: 1. Micro-teaching and 2. Educational posters.

Results

The majority of patients had a pre-existing diagnosis of cognitive impairment (n=58, 64.4%). Prior to intervention, 4AT was documented infrequently at clerking (n=8, 26.7%) and at post-take review (n=14, 46.7%) but more frequently once admitted to the inpatient ward (n=21, 70%). Following the teaching intervention, no change was observed in frequency of 4AT completion during admission clerking (n=6, 20.7%) and post-take review (n=9, 31.0%). 4AT completion increased during inpatient review by 16.2% to 86.2% (n=25). Following distribution of posters and visual aids, 4AT completion rates did not change at admission clerking (n=7,  23.3%), post-take (n=6, 20.0%) and during inpatient review (n=26, 86.7%).

Conclusion

4AT completion was infrequent, particularly at admission. Microteaching increased frequency of 4AT completion for elderly medicine inpatients. There was no improvement in completion at admission (clerking and post-take). Posters and visual aids had limited impact. Microteaching could be a valuable strategy to prompt behaviour change amongst doctors. Further work could identify barriers to 4AT completion at admission and strategies to improve completion.