Introduction to ‘Immediate management of delirium care bundle’ and change package

Karen Goudie, Clinical Advisora

Michelle Miller, Improvement Advisor

Healthcare Improvement Scotland

Delirium Patient Story

• Video from European Delirium Association

Population of Scotland

Delirium • Older People are frequently labelled as

confused on admission and throughout hospital stay

• Delirium is a disturbance of consciousness, attention, cognition and perception that develops over a short period of time. It is a serious condition associated with poor outcomes.

• Delirium is a Medical Emergency that warrants immediate attention from staff

Delirium • The prevalence of delirium in people on

medical wards in hospital is about 20% - 30%• 10%-50% of people having surgery develop

delirium• The incidence of delirium will vary across

clinical areas• Reporting of delirium in the UK is poor

indicating that awareness and reporting procedures need to be improved

People who develop delirium may

• Need to stay in hospital longer• Have increased incidence of dementia • Have more hospital-acquired complications

such as falls and pressure sores• More likely to need to be admitted to long

term care if they are in hospital• More likely to die (NICE, 2011)

Identification

4AT Tool

Delirium Immediate Care BundleGuidance (first 2 hours)

TRIGGERS

Severe illnessTrauma/surgery

PainInfection/Sepsis

DehydrationHypoxia

Hypoglycaemia Medication s

FrailtyAlcohol and drugs withdrawal

Urinary Retention /Constipation

InvestigateRoutine Bloods

INVESTIGATE

FBC, U&Es, CRP. LFTs Glucose, Mg, Ca+,phos, Consider ABG

Culture Urine, sputum, wounds , Consider Blood Culture (Sepsis Six) CXR

urinalysis

Always carry out routine Observations (EWS) including

AVPU and Think glucose.Start Fluid Balance

Think about Hydration Status

MANAGE First and foremost treat

underlying causesManage sepsis

Refer to The SDA Pathway for complete care guidance

Provide environmental and personal orientation

Do NotUse Restraint

Do not Sedate Routinely (See SDA Pathway)

EXPLAINFamilies and Carers Can

give you a history of change always speak to them to obtain history and baseline function

Families and Carers can help reorient

Always Document Delirium Diagnosis

Assess Capacity Consider AWI Form

(section 47)

Refer to Scottish Delirium Association for complete care pathway

To improve the identification and immediate management of delirium for people aged 75 and over being admitted to acute care, by March 2014, to achieve 95% compliance with all elements of the care bundle.

Immediate Management of

delirium

Think Delirium - Identification of

Delirium

Education, leadership and

culture

Aim

Primary Drivers Secondary DriversThink Delirium - Screening on admission to identify delirium •Screening of patients over 75 years being admitted to acute care, to identify delirium, using a screening tool (eg 4AT)•Document diagnosis of delirium (where positive screening)•Create a culture that supports family and carer involvement in care•Promote the use of patient, family, carer feedback to improve care•Ensure patient requirements are accurately reflected in the care plan

Improving Care for Older People in Acute Care: Delirium Driver Diagram

Immediate Management of delirium (2 hours from diagnosis of delirium)•Test the delirium care bundle within local context for usability•Test the delirium care bundle to achieve compliance and reliability•Reduce the time for implementation of care bundle•Create a culture that supports family and carer involvement in care•Avoid inappropriate inter and intra ward transfers•Link to Scottish Delirium Association Pathway (or local pathway) for further management

•Develop an infrastructure to support local testing of the delirium bundle using improvement approaches•Develop educational resource to support identification and management of delirium •Align work with other relevant work streams including wider older peoplels improvement work, person centred health and care, dementia strategy, Scottish Delirium Association Pathway and NHS Education for Scotland educational resources•Optimise opportunities for spread •Optimise opportunities to learn from and share good practice

Measures and Data Collection - Delirium

Core Measures

Screening for delirium (using 4AT or locally agreed tool)Compliance with individual elements of the delirium bundleCompliance with overall elements of the bundle

Reporting

enter data on excel spreadsheet - run charts automatically generated and populate monthly report – add in challenges and highlights

Send monthly report – last Friday of every month

Aim: improve the identification and immediate management of delirium to achieve 95% compliance with all elements of the care bundle

Learning from the Experience of Patients, Families/Carers and Staff

•Interviews with patients, families and carers•Focus Group with staff•Digital Story•Learning about Experience Cards