Background: Delirium is a common and serious complication of acute illness in elderly patients that frequently goes undiagnosed. Its pathophysiology is often poorly understood by many clinicians, but the abnormalities in physiology are usually transient, reversible and preventable. It is sometimes referred to as ‘acute brain failure’. The 4 A’s test (4-AT – alertness, age, attention, acute changes) is a simple and fast way of screening for delirium. A Healthcare Improvements Scotland inspection of Dr Gray’s Hospital, Elgin in April 2017 revealed that the 4-AT was often being underused and incorrectly completed. 4-AT usage was audited and then a tailored educational intervention aimed at increasing and improving 4-AT usage was delivered. Methods: The medical and nursing notes of inpatients aged 65 and over on the Acute Care for the Elderly (ACE) ward were assessed for the presence of correctly completed 4-ATs on 15th January 2018. Junior clinicians (n = 11) were surveyed to identify reasons for non-completion before viewing a video demonstrating the quick and easy nature of the 4-AT and an infographic explaining 4-AT scoring. They were then surveyed on this educational intervention. The audit was repeated on 16th March 2018. Results: 4-AT completion rate increased from 57.7% to 60.9% between January and March (N.S. p>0.05). However, clinicians reported that over 80% felt they were using the 4-AT on all elderly admissions. 55% said they had had trouble completing a 4-AT assessment, particularly the final section where they had to judge acute changes in physiology or fluctuating pathophysiology. Junior doctors scored the video and the infographic 7/10 and 6.4/10 respectively but 67% disagreed that it made them more likely to carry out the 4-AT in all elderly admissions as they felt they already completed it regularly. Reminder stickers on patient notes and incorporation of the 4-AT into clerking forms were suggested as further interventions by respondents. Conclusion: 4-AT completion was not acutely improved by the intervention indicating the need for a more wide-reaching, thorough intervention. The educational intervention seemed to be effective in demonstrating how to overcome issues with 4-AT completion. It did identify that there were major issues with the perceptions clinicians had of how often and effectively they were completing the 4AT documentation, compared to reality. This work is being shared and taken further by NHS Grampian to further enhance use of this screening tool and to minimise the impact of delirium on patients and healthcare providers. The audit will be repeated later this year to check for any long-term improvements in 4AT awareness and completion. This project also demonstrates that science students may effectively undertake quality improvement work as part of an Honours capstone project to benefit the NHS and the local population.
|Publication status||Published - 2019|
|Event||Physiology 2019 - Aberdeen Exhibition & Conference Centre, Aberdeen, United Kingdom|
Duration: 8 Jul 2019 → 10 Jul 2019
|Period||8/07/19 → 10/07/19|