85 I DO, I CARE: implementing delirium screening for older people to improve care, awareness and recognition in the emergency department

Abstract

Abstract Background Delirium is prevalent (7%–20%) in older patients in emergency departments (ED). The diagnosis is often missed (57%–83%). This Quality Improvement (QI) project aimed to improve delirium screening by 30% in the ED, in keeping with the HSE’s ‘Early Identification and Management of Delirium in ED (2021) and to identify barriers to sustain screening. Methods The Institute for Health Improvement Quality Improvement essentials toolkit was used. Patients ≥75 years with Manchester triage category of 2–5 were included. Plan Do Study Act cycles included auditing 110 patient charts in a weekly rapid cycle audit was performed. Actions included 1) formation of an organisational oversight group 2) triage nurses and healthcare assistants placed ‘Screen me with 4AT’ stickers on charts 3) ED Doctors screened with 4-AT 4) 4AT tool was incorporated into all adult proforma 5) 5 face to face information sessions with ED nurses 6) 8 individualised information sessions with ED nurses 7) EM registrar education of junior doctors 8) 4-AT lanyard reminder card 9) twice-weekly WhatsApp group sharing of results 10) Informal feedback invited from doctors who did not complete the 4AT. Data was entered onto Excel and analysis done using descriptive statistics. Results The mean (SD) age was 84 (5.6) years, the mean (SD) Manchester triage was 2.6 (0.6) and 56% were female. At baseline 1/20 (5%) charts contained a completed 4-AT. On average the 4-AT completion improved to 38% (42/110) (range 10% to 60%). Delirium was diagnosed in 38% (16/42). Barriers identified pre and post implementation included knowledge deficits, no out-of-hours referral pathway, low priority above competing demands, and fluctuations in ED staffing. Conclusion The QIP achieved the target but sustainability due to doctor’s rotations is questionable. Senior clinical leadership and role modelling, nursing team buy-in, education, and referral pathways are required to build on current progress.