Use of 4AT for delirium screening in geriatric patients

Background: Delirium is a common, under-recognised and under-diagnosed condition in hospital, which can be assessed by the ‘4-A’s’ Test (4AT), as recommended by NICE. The 4AT test requires minimal training and is used broadly, including in patients with reduced consciousness and drowsiness. NICE considers the 4AT to be practical and accurate in most clinical settings. Recent research supports its performance; one 2026 meta-analysis by Keane et al., demonstrated a pooled sensitivity of 88% and specificity of 79% for detecting delirium in patients with dementia. This QIP aimed to increase 4AT completion and documentation during clerking, supporting earlier recognition and assessment of delirium. 

Methods: We retrospectively reviewed OPS clerking booklets across the participating wards to establish baseline 4AT utilisation; our initial audit demonstrated a compliance rate of 26%. We introduced colleague education to raise awareness of 4AT’s role in assessment of delirium. Following a re-audit, we introduced a second intervention; posters displayed throughout participating units as a simple visual reminder to complete 4ATs. A further re-audit then assessed whether this intervention led to a further improvement in compliance. 

Results: Our initial audit demonstrated 26% of patients had a documented 4AT. Following colleague education, compliance increased to 34.2%. After introducing posters across all participating units, compliance increased further to 75%. This demonstrated a progressive improvement in 4AT completion following each intervention and highlighted the potential impact of simple, practical interventions on everyday clinical practice. 

Conclusion: This QIP demonstrated that simple interventions, such as colleague education and visual reminders, improve compliance with 4AT completion and documentation. Although initial compliance was low, each intervention resulted in improvement, suggesting that tool awareness and accessibility were important factors. Our next step will be to incorporate the 4AT directly into post-take sheets, making it routine clinical practice and ensuring compliance is sustained over time.