TIME to think about delirium: improving detection and management on the acute medical unit

Abstract

Delirium affects 18%–35% patients in the acute hospital setting, yet is often neither detected nor managed appropriately. It is associated with increased risk of falls, longer hospital stay and increased morbidity and mortality rates. It is a frightening and unpleasant experience for both patients and their families. We used quality improvement tools and a multicomponent intervention to promote detection and improve management of delirium on the acute medical unit (AMU). We reviewed whether a delirium screening tool (4AT) had been completed for all patients aged over 65 years admitted to the AMU over 1 week. If delirium was detected, we assessed whether investigation and management was adequate as per national guidance. After baseline data collection, we delivered focused sessions of delirium education for doctors and nursing staff, including training on use of the 4AT tool and the TIME (Triggers, Investigate, Manage, Engage) management bundle. We introduced TIME checklists, an online delirium order set and created a bedside orientation tool. We collected data following the interventions and identified areas for further improvement. Following our first PDSA (Plan, Do, Study, Act) cycle, use of the 4AT screening tool improved from 40% to 61%. Adequate assessment for the causes of and exacerbating factors for delirium increased from 73% to 94% of cases. Use of personal orientation tools improved from 0% to 38%. In summary, a targeted staff education programme and practical aids for the ward have improved the screening and management of delirium on the AMU. This may be improved further through more frequent training sessions to account for regular change-over of junior doctors and through implementing a nursing champion for delirium.

Delirium

“…However, there is growing interest in quality improvement approaches, which seem to show promise. For example, a combination of staff education and use of the Think, Investigate, Manage, Engage (TIME) bundle 241 , which targets delirium treatment actions in the first 2 hours following diagnosis, led to improvements in the assessment of delirium causes and exacerbating factors 272 . Furthermore, educational interventions can lead to improvements in the process of care; a systematic review of 42 studies involving educational interventions found that 90% of these studies demonstrated a beneficial effect on one or more measures, some of which were related to the delivery of delirium treatment 273 .…”

Delirium is prevalent in older hospital inpatients and associated with adverse outcomes: results of a prospective multi-centre study on World Delirium Awareness Day

“…We suggest that in an acute hospital environment, a positive 4AT highlights patients at increased risk of adverse outcome. We recommend pairing of a comprehensive delirium management strategy (such as the TIME Bundle from the Scottish Delirium Association) [46].…”

Impact of a dementia-friendly program on detection and management of patients with cognitive impairment and delirium in acute-care hospital units: a non-equivalent control group design

“…Previous studies aimed at improving the use of 4AT screening have shown a 21-64% improvement of screenings (45)(46)(47)(48). However, Bearn et al (47) was the only study with a baseline screening of 0%, as in our study, implying that the 4AT instrument was already known and in use by the healthcare staff in the other studies.…”