Use of 4AT and delirium diagnosis on admission in a district general hospital.

Introduction

Delirium is a common and significant, but often underidentified cause of morbidity and mortality in older inpatients. Screening improves detection, management, patient outcomes, length of stay and readmission rates. NICE recommends the 4AT as the optimal screening tool for its accuracy, accessibility, and simplicity. The Trust’s protocol mandates 4AT assessment on clerking for all patients aged 65+. 

This project's primary aim was to audit 4AT screening on admission in the Geriatrics department. Secondary aims assessed documentation clarity: whether high 4AT scores (≥4) triggered diagnosis, and whether precipitating sub-causes were considered.

Methodology

Each cycle, conducted on Pinderfield Hospital's Geriatric admission ward, involved 6 and 5 sample days respectively, over 9 and 7 weeks, with ≥6 days between sample days to allow for new patients. All included patients had been post-taked by the consultant. Electronic health records were reviewed retrospectively for use of the 4AT form, clerking and ward round entries. 

Total n= 472 (cycle 1 n= 262, cycle 2 n= 210). Interventions after the first cycle were governance presentation, departmental teaching, posters and email reminders.

Results

Primary aim: admission 4AT assessment rose from 59% to 84%, with high use of its electronic form (97%; 98%). Admission 4AT in patients with delirium symptoms (confusion, lethargy) rose from 55% to 86%.

Secondary aims: Patients labelled "too confused for 4AT" occurred only pre-intervention. High-scoring 4ATs consistently lacked written consideration and diagnosis of delirium in both cycles. Precipitating factor documentation remained poor (35%; 31%) with infection, constipation and retention considered more consistently than other sub-causes.

Conclusions

Admission 4AT screening has improved significantly, including among symptomatic patients (primary aim). Documentation of reasoning when delirium non-diagnosis despite high scores and sub-cause consideration remain areas for improvement (secondary aim). This will be incorporated into induction for doctors at all levels, with re-audit planned from September.