Rapid Micro-PDSA Cycles to Optimize 4AT Delirium Screening Compliance Across the Acute Surgical Take

Introduction

Delirium heavily impacts older adults undergoing emergency surgical admission, where perioperative stressors introduce a critical need for screening. The 4AT is a validated tool for rapid assessment. Whilst screening is robust in medical take, surgical compliance remains poor. This QIP aimed to improve 4AT compliance and reduce time to screening for older people aged ≥65 across the acute surgical take.

Methods

A baseline audit evaluated older individuals aged ≥65 admitted via the surgical take. Cycle 1 was run over 6 days, introducing computer bezel stickers in clerking areas and wards. Following feedback and data analysis, Cycle 2 was deployed for 4 days; this cycle abandoned ward-based prompts due to lack of impact, shifting focus entirely to acute intake via high-impact workflow posters in the surgical clerking room. Compliance and median time to completion were tracked across cycles.

Results

Baseline audit showed a 40% (n=8/20) overall 4AT compliance rate. Compliance was heavily skewed; Trauma & Orthopaedics (T&O) accounted for 75% (n=6/8) of completions at initial assessment, whilst general surgery compliance was poor. Baseline median time to completion was 18 hours. Following Cycle 1, compliance remained at 43% (n=6/14), but median time to completion dropped to 6 hours (target 24 hours). Qualitative feedback from frontline staff revealed that non-compliance was driven by an educational deficit regarding 4AT execution. Following Cycle 2, data collection showed an overall 4AT compliance rate of 50% (n=2/4) and a median completion time of 19 hours.

Conclusions

While visual prompts accelerated screening speed, they hit a clear compliance ceiling due to underlying educational gaps. Sustainable compliance will require structural forcing functions. Consequently, parallel future tracks are underway: PDSA Cycle 3 will focus on targeted peer education to address the knowledge deficit and PDSA Cycle 4 on Electronic Patient Record (EPR) forcing functions.