“We used to record people as ‘confused’,” says nurse manager Sarah Jenkin. “Now we write ‘delirium’, and take appropriate action to manage the condition."
Sarah’s ward at Monash Health Service, Casey campus, is the best-performing site in the Safer Care Victoria delirium collaborative that aims to improve the care of older patients in hospital by doing more to prevent, identify and manage delirium.
Delirium is “acute brain failure” – explains geriatrician Dean Everard – and needs to be recognised as such. It can be triggered in older people when they are admitted to hospital as a side effect of things such as medication, infection or dehydration and is compounded by an unfamiliar environment. Unrecognised and untreated delirium can lead to an increase in falls, hospital length of stay and mortality.
The Monash Casey team on Ward H is leading the statewide collaborative in using the 4AT delirium screening tool for every new admission. Prior to the start of the collaborative they didn’t consistently screen for delirium. Nor did most of the other 21 teams involved in the collaborative. Now it is part of their standard work.
From a low baseline of 25 per cent of patients screened for potential delirium (n= 685), the 21 teams are now screening 78 per cent of patients (n=1092). At Ward H they are now screening close to 100 per cent of patients within 24 hours of admission.
At Monash, an assessment of potential delirium leads to a chain of other actions, such as incorporating the information into the patient’s individualised care plan. They also take a multidisciplinary to reduce the delirium severity. This involves a sunflower diagram on a wall that records details of the patient’s life that are important to them – things like their preferred name, footy team, pets, number of grandchildren. Important details that everyone from the cleaner to the night staff can use to start a quick conversation.
Cognition clinical lead Brianna Walpole says the Monash response also involves collecting information about the patient’s routines. For example, if an older woman regularly takes her dog for a walk at 2.30pm, it is not uncommon that at that time she would become restless. One response would be to schedule physiotherapy for that time. “By knowing more about our patients’ lives and routines we can improve our care,’’ Brianna says.
Improving recognition of delirium and triggering better clinical responses has led to a steep reduction in the use of anti-psychotics on the ward which, geriatrician Dean Everard says, is a very positive outcome. Anti-psychotics, he explains, are sometimes prescribed to people overnight, not because they are psychotic but because one side effect is sedation.