Improving recognition and management of acute delirium in older adults: A quality improvement project

Introduction

Delirium in older adults is associated with increased morbidity, functional decline and mortality. NICE recommends the use of the 4AT within 24 hours of admission in adults aged ≥ 65 years. However, completion rates in clinical practice remain suboptimal. This quality improvement project aimed to improve recognition of acute delirium on a geriatric ward in Queen’s Hospital, by increasing the proportion of new ward admissions with a documented diagnosis of delirium and corresponding management plan by 20% through improved use of the 4AT.

Methods

Baseline data were collected over one week, measuring delirium recognition and 4AT completion for new admissions. Three PDSA cycles were implemented over six weeks: (1) paper-based 4AT proformas and ward posters, (2) electronic prompts during the Trust’s transition from paper to electronic notes and (3) dissemination of an educational video on delirium. Weekly data collection assessed outcome, process and balancing measures.

Results

At baseline, only 5.56% (n=18) of new admissions had documented delirium with a management plan, with 4AT completion at 5.56%. Delirium recognition improved progressively, reaching 44.44% (n=18) during PDSA cycle 2 and 46.7% (n=15) by the end of cycle 3, exceeding our 20% goal. 4AT completion increased to 50% during PDSA cycles 1 and 2, however this was not sustained, falling to 0% by project end. 71% (n=7) of clinicians reported no perceived increase in workload associated with delirium screening.

Conclusion

Our interventions improved delirium recognition, despite a period of digital transition. Whilst improvements in 4AT completion were not sustained, overall delirium recognition improved through combined use of 4AT and clinical judgement. Our paper proformas, posters and educational material can be scaled Trust-wide and integrated seamlessly into Mandatory and Statutory Training. However, longer PDSA cycles, wider multidisciplinary engagement and consideration of the new electronic patient record is essential for durable system-level change.