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

Karen Goudie, Clinical Advisor a 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 Bundle Guidance (first 2 hours)

T RIGGERS I NVESTIGATE

Severe illness Trauma/surgery Pain Infection/Sepsis Dehydration Hypoxia Hypoglycaemia Medication s Frailty Alcohol and drugs withdrawal Urinary Retention /Constipation 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

M ANAGE

First and foremost treat underlying causes Manage sepsis Refer to The SDA Pathway for complete care guidance Provide environmental and personal orientation Do Not Use Restraint Do not Sedate Routinely (See SDA Pathway) Refer to Scottish Delirium Association for complete care pathway

E XPLAIN

Families 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)

Aim

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

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.

Primary Drivers

Think Delirium Identification of Delirium Immediate Management of delirium

Secondary Drivers

Think 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

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

Education, leadership and culture

• • 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

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

Core Measures

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

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