Lessons and limitations
This project was carried out over two AMUs with data collection over two periods of 7 days. Expanding this onto other wards and collecting data over a longer period of time will give us a stronger indication of whether our interventions have brought about improvements; the improvements in rates of delirium diagnosis and adequate investigation and management may be statistically non-significant due to small sample sizes. Due to time constraints, we implemented several interventions into one single PDSA cycle rather than carrying out multiple cycles. We felt that targeting several key areas at the same time would be more likely to improve the overall management of the condition. Nevertheless, as a result we cannot determine whether it was one single intervention in particular or the combination of interventions that brought about change.
Despite this, due to the complex nature of delirium and the multidisciplinary nature of the team involved, we believe that the decision to use a multicomponent intervention is warranted. As our project spanned over several months, a number of the junior doctors who took part in the education programme were no longer on AMU by the time the second set of data were collected, and we expect that for a sustained change to take place we would need to organise regular teaching to account for junior doctors rotating.
It is well recognised that in order to implement change successfully within a healthcare system, one needs to understand the problem, the target group, the setting and the obstacles to change.33 In our case, barriers at each of these levels contributed to for the shortcomings in fully reaching our SMART aims. The ‘problem’, that is, delirium itself can be confusing and frustrating for medical and nursing staff due to its multifactorial aetiology, varying presentation, fluctuating and often prolonged course. The ‘target group’ in this case were junior doctors on the acute medical take and nursing staff on AMU; two groups under significant time pressure who have a level of understandable reluctance to take on any extra measures that are time consuming. The ‘setting’, an AMU, is set up for short admissions and prompt transfers/discharges. The culture among staff on AMU very much reflects this. This makes implementing changes for a geriatric population of patients with multiple-morbidities challenging.
Nonetheless, this project contributes to the literature showing that educational interventions can improve delirium management in the acute medical setting.22 23 34 We note that other quality improvement projects in similar settings have not reported an increase in screening of delirium35 or report difficulties in accuracy of assessment by ward nursing staff.34 Factors that may have improved screening in this project may include (1) the use of 4AT as opposed to other screening tools and (2) the emphasis on the admitting junior doctor having the responsibility of recognition, rather than ward medical/nursing staff.
It has been frequently noted that it can be challenging to incorporate evidence and guidelines into practice when it involves a change in culture and routine. One way to tackle this is to use a more broad approach, targeting distinct members of the multidisciplinary team.36 This is why we felt it essential to include doctors, nurses, speech and language therapists and occupational therapists in this project.
Key themes we noted from staff feedback were particularly centred on attitudes towards delirium itself, in particular a belief that managing a multitude of small factors ‘won’t make a difference’ to a disease course, problems with time pressure for example, not having time to include a 4AT screening tool in a clerking on a busy medical take, and a reluctance to engage with ‘more paperwork’. The nursing staff felt that there was a lack of leadership among them regarding delirium. In retrospect, we may have benefited from recruiting a nurse onto the project team in order to increase nursing ownership and engagement with the problem. We are now planning to recruit a ‘delirium champion’ to each ward involved which we hope will help to increase and sustain change, as previous studies have shown that the appointment of ‘dementia champions’ has altered health professionals’ perception of dementia.37
There were often conflicting views from medical and nursing staff regarding an understanding of the use of the Mental Capacity Act38 in patients with delirium and acting in patients’ best interests, particularly regarding the need for patient consenting to the use of orientation tools by their bedside. This restricted its use in some cases. Further delirium education sessions for nursing staff could address this in order to provide clarity on this issue.
In the ‘act’ phase of this PDSA cycle, we will adapt our interventions and test again. Specifically, we will aim for multiple education sessions over several months in order to reach the maximum number of staff.