005202 – Delirium and Cognitive Impairment Care Pathways Procedure

Caboolture and Kilcoy Hospitals and Woodford Corrections Health Service 

Procedure 

Effective from: January 2020

Review date: January 2023

Delirium and Cognitive Impairment: Care Pathways

 

Purpose and intent

People with cognitive impairment have problems with memory, communication and/or thinking that can be temporary and/or long term.  Common causes of cognitive impairment for older patients in hospital are impaired cognition and/ or delirium. Patients with impaired cognition and/ or delirium are at increased risk of preventable complications and adverse events, such as falls and pressure injuries, and require additional care to prevent harm.  However, cognitive impairment is often not identified and /or the risks of harm are often under recognised or dismissed (ACSQH, 2014). Those with cognitive impairment are at greater risk of Delirium.

Delirium is an acute change in mental status, characterised by a disturbance of consciousness, attention, cognition and perception that develops over a short period of time. Delirium is a common preventable cause of patient morbidity and mortality. Delirium can be associated with higher risk for postoperative complications, longer recuperative periods, longer hospital stays and long-term disability. The elderly are particularly susceptible with an increased incidence of persisting deficits. Delirium may be a sign of underlying disease such as infection or myocardial infarction. Despite this knowledge, only 32-66% of patients are identified, properly diagnosed and treated. This substantially increases the risk of poor outcomes. Primary prevention, early recognition, and prompt and effective treatment are, therefore, of paramount importance.

Delirium Care Pathways are developed to assist in early identification of impaired cognition and/or delirium to assist in the coordination of care whilst improving their management to improve care, prevent hospital acquired delirium and minimise adverse outcomes. This document builds upon the Clinical Practice Guidelines for the Management of Delirium in Older People to provide a blueprint that guides clinicians in the provision of care.

The intent of this procedure is to improve the early recognition of and response to patients with cognitive impairment so that they receive safe and high-quality care. 

Scope and target audience

This document is for all Caboolture and Kilcoy Hospitals staff (permanent, temporary and casual) and all organisations and individuals acting as its agents (including Visiting Medical Officers and other partners, contractors, consultants, volunteers and students) to understand clinical practice in the management of patients with delirium and/ or cognitive impairment.

Procedure / process

Risk Identification

Confusion is not a normal part of ageing. Cognitive screening for older people is often overlooked during initial admission processes. This can lead to the assumption that any confusion identified during admission is related to dementia. As a result, the diagnosis of delirium is often missed. Patients with identified risk factors (including people greater than 65 years or Australian Torres Strait Islander (ATSI) greater than 45 years) should have a cognitive risk screen completed on presentation to hospital.

If the older person is confused and risk factors for delirium are present, then the cause of their confusion should be assessed within 24 hours of admission (via the Emergency Department admissions process or as a result from the Patient Risk Assessment, upon admission to the ward)

The first step in screening an older person for impaired cognition and/or delirium is completing a baseline cognitive screen which can include the following:

Completion of the4AT (Appendix 1): this is a validated screening tool for the assessment of delirium and cognitive impairment and should be performed on admission in ‘at risk’ patients and if there are any changes in patient behaviour or cognition, the 4AT is a screening tool designed for rapid assessment of delirium and cognitive impairment.  It is a short and practical tool that is designed for rapid assessment when delirium and/ or cognitive impairment is suspected.  The tool should be used at first contact with a patient and at other times during the admission to identify a decline in patient’s cognition. 

Examples of alternate cognitive assessments are:

  • The Folstein Mini Mental State examination (MMSE) – Scores of less than 24/30 suggest impaired cognition (Appendix 2)
  • The Rowland Universal Dementia Assessment Scale (RUDAS) – multi-cultural mini mental state examination (Appendix 3)
  • Kimberly Cognitive Assessment (Appendix 4)

Delirium is a complex interplay between predisposing and precipitating factors. Patients with more predisposing factors are more vulnerable to precipitants of delirium.

Predisposing Factor for delirium may include: dementia, medical illness/ co-morbidity, alcohol use, depression, older age (65+ or for ATSI 45 + years), polypharmacy, Psychoactive drugs, vision/ hearing impairment, decline in activities of daily living-dependence, dehydration and hyper/hypoglycaemia.

Precipitating Factors which may cause or contribute to delirium may include: Acute illness, infection, alcohol/drug use, polypharmacy, three or more medications introduced, drug withdrawal, surgery or complications of surgery, metabolic derangement of encephalopathy, anaesthetic, postoperative pain, complications of medical procedures, dehydration, sleep deprivation physical restrain, indwelling catheter (IDC), cardiovascular event, stroke, malnutrition and PITCHED.

If the person does not have confusion, then cognitive screening should be repeated if:

  • there is any sudden change in the person’s condition (including behaviour and cognition changes)
  • there is a sudden decline in the person’s ability to perform activities of daily living (ADLs)
  • a carer or family member expresses concern.

Aboriginal and Torres Strait Islander considerations

People who identify as Aboriginal and/or Torres Strait Islander need to have additional considerations when assessing for delirium and/or impaired cognition. As noted above their risk occurs at an earlier age and assuch may be missed so additional care needs to be undertaken in the screening process whilst promoting education on delirium and/or cognitive impairment.

Cultural norms and/or beliefs may also impact the assessment or ability to assess Aboriginal peoples and Torres Strait Islander peoples so refer to culturally appropriate care as outlined in the  Metro North Better Together Plan or the Queensland Health Aboriginal and Torres Strait Islander Cultural Capability Framework 2010-2033 to provide individualised care. When attending cognition assessments, it is suggested that First Nations people are assessed using the Kimberly Cognitive Assessment.

Cultural rights for the person with delirium and/or cognitive impairment may also be impacted whilst receiving care and all efforts must be taken to respect, protect and promote these rights as per section 28 of the Human Rights Act 2019 (Qld).

Response to Delirium and Cognition Screen

Upon completion of the 4AT screening tool, staff should use the 4AT scoring guide (Appendix 4) to support their actions in addition to notifying the treating medical team of the result. This tool was developed in conjunction with staff and consumers to clearly articulate the expectations in providing best practise.

This tool references standard care expectations, patient education and reinforces the use of PITCHED principles (Appendix 5), increased rounding and observation, referrals to relevant AH and medical staff for additional cognitive assessment and other current management strategies as available in Admission to the GLAD (Gentlemen and Ladies Aging with Dignity) Unit procedure: https://qheps.health.qld.gov.au/__data/assets/pdf_file/0029/1819910/004134.pdf

Positive screens (>0) indicate cognitive impairment and/or delirium and a hospital wide delirium treatment pathway has been developed (Appendix 6) to support staff across the acute hospital setting (exception GLAD as own delirium pathway in place). This document references the current considerations for all staff and supports the current Admission to the GLAD Unit Procedure (including the Sunflower form and Delirium pathway) in addition to the CPO request form required at Caboolture Hospital to support current best practise guidelines for caring for the person with delirium and/or cognitive impairment. 

Patient and Staff Education

The patient and their family (in addition to care providers as relevant) will require reassurance that the standard of care and support will be maintained over the care continuum. Education on delirium and prevention strategies in the context of cognitive impairment should be a priority (Delirium brochure – Appendix 7).

All staff should be aware of the impacts of delirium and/or cognitive impairment to minimise confusion and decrease risks associated with environmental changes.  Engagement and involvement of the patient and/or their families/care providers in developing their plan of care goes a long way to improving outcomes and minimising deterioration (including hospital acquired delirium and/or unnecessary intervention). (Educator escalator – Appendix 9)

Patient transfers, care continuity and transition

Consider all needs of patients (including cultural and religious belief) and involve their family/carers and care providers in the comprehensive handover of care if the patient needs to be transferred to another clinical location. Patients with impaired cognition and/or delirium are at increased risk in the face of unfamiliar environment and changed routines. All possible avenues to prevent these actions should be explored prior to transferring these patients.

Post admission it is important to ensure adequate education about long term effects of delirium and management of cognitive impairment. It is essential that follow up (either in primary care setting with their GP, or relevant referrals for OT/geriatrician/memory clinics) is attended as required.

Partnering with consumers

Consumer representatives were involved in the review and re-writing of this Procedure document. The entire document has been written in such a way that it can be given to patients, relatives and carers to explain our care of patients requiring restraint and to outline their valued involvement in that care.

If preferred, Appendix 8 or NSQHS consumer/clinician factsheets https://www.safetyandquality.gov.au/standards/nsqhs-standards/partnering-consumers-standard can be printed separately for patients, carers/relatives and or staff.

Legislation and other authority – Consent and restraints

Consideration of human rights and dignity is very important for a person with impaired cognition and/or delirium. It is essential to undertake a holistic assessment of a person with impaired cognition and/or delirium to consider each person’s human rights and provide treatment in accordance with the Human Rights Act. Human rights may be impacted in the due course of their care but should only be limited where reasonable and demonstrably justified under the Human Rights Act.   

Cultural Rights for Aboriginal peoples and Torres Strait Islander peoples and culture/beliefs and norms for all people must be taken into account to ensure that management of the person with cognitive impairment and/or delirium is appropriate. Use of an interpreter or modified/individualised assessments to accommodate for language/health literacy etc is imperative. Consumer education on cognition is important to ensure the patient and/or carer is understanding of prevention/management particularly where there arelimitations placed on the person in context of consent and restraint.

Consent

The person with impaired cognition and/or delirium may or may not be deemed to have capacity to make informed decisions. Capacity can be considered fluid and it is essential that personal privacy and dignity is upheld whilst assessing each situation. Section 30 of the Human Rights Act states that “[a]ll persons deprived of liberty must be treated with humanity and with respect for the inherent dignity of the human person”.

Where there are concerns for a person’s safety it is important to maintain their dignity and privacy whilst ensuring their safety. An appropriate substitute decision maker may need to be allocated to make decisions on behalf of the person with delirium and/or cognitive impairment where that person has impaired capacity to make a decision about a specific question regarding their healthcare. In this context the following applies;

  • In the event of an emergency and where an adult patient has impaired capacity, section 63 of the Guardianship and Administration Act 2000 (Qld) (“Guardianship and Administration Act”) provides for healthcare to be rendered as urgent treatment without consent only in response to imminent risk to life or health, suffering or distress. In such circumstances, section 75 of the Guardianship and Administration Act provides for “a health provider and a person acting under the health provider’s direction or supervision may use the minimum force necessary and reasonable to carry out healthcare authorised under this Act”. However, attempts should be made to seek prior consent from the appropriate substitute decision-maker if possible.
  • The appropriate substitute decision-maker will be first in the following order as per s 66 of the Guardianship and Administration Act:
    • A guardian appointed by the Queensland Civil and Administration Tribunal;
    • An enduring power of attorney pursuant to enduring documents;
    • A statutory health attorney being the first of the following:
      • a spouse of the adult if the relationship between the adult and the spouse is close and continuing;
      • a person who is 18 years or more who has the care of the adult and is not a paid carer for the adult;
      • a person who is 18 years or more who is a close friend or relation of the adult and is not a paid carer for the adult,

as per s 63 of the Powers of Attorney Act 1998 (Qld).

 

All decisions made on behalf of the patient requires consideration of the patient and/or their families wishes and must support the optimum care of the patient. In instances where restraint (including secure environments and/or close observation) are actioned consent needs to be obtained from the appropriate substitute decision maker.

Restraints

Restraints should be a measure of last resort and where possible all efforts should be made to minimise the use of restraints for a person with delirium and/or cognitive impairment.

Restraint Procedure

Please refer to Minimising Aggression and Restraint 005089 Procedure

After the use of Restraint

Any restraint process (physical and/or pharmacological) needs review on a regular basis.

Audits surrounding the use of physical restraints should be attended in line with this policy.

Medication considerations should be reviewed as per Delirium Treatment pathway (Appendix 7) and an audit schedule surrounding medication use in delirium and/or cognitive impairment is under development.

References

  • Australian Society for Geriatric medicine (2012) Position Statement No.2 Physical Restraint Use in Older People Sept 2012
  • Australian Commission on Safety and Quality in Healthcare (2010) Patient-Centred Care: Improving Quality and Safety by Focussing Care on Patients and Consumers
  • Dierckx de Casterle B, Goethals S, Gastmans C (2015) Contextual influences on nurses’ decision making in cases of physical restraint Nursing Ethics Vol 22(6) 642-651
  • Enns E et al (2014) A Controlled Quality Improvement Trial to Reduce the Use of Physical Restraints in Older Hospitalized Patients Journal America/ Geriatrics Society62: 541-545
  • Goethals S, Dierckx de Casterle B, Gastmans C (2013) Nurses’ ethical reasoning in cases of physical restraint in acute elderly care: a qualitative study Medical Health Care and Philosophy 16:983-991
  • Heinze C, Dassen T, Grittner U (2011) Use of physical restraints in nursing homes and hospitals and related factors: a cross-sectional study Journal of Clinical Nursing 21: 1033-1040
  • Kruger C et al (2013) Use of physical restraints in acute hospitals in Germany: A multi-centre crosssectional study International Journal of Nursing Studies 50: 1599-1606
  • Lack H, Leach K (2016) Changing the Practice of Physical Restraints Use in Acute Care Journal of Gerontological Nursing Vol 42(2) 17-26
  • Raguan B, Wolfovitz E, Gil E (2015) Use of Physical Restraints in General Hospital: a Cross-Sectional Observational Study! MAJ Vol17 Oct 2015 633-638
  • Ralph M. Meyer G (2014) Attitudes of nurses towards the use pf physical restraints in geriatric care: A systematic review of qualitative and quantitative studies International Journal of Nursing Studies 51 (2014) 274-288
  • The Prince Charles Hospital (2019) [Procedure] PROC003016 Physical and Mechanical Restraints – Patients Version No: 2.0 Effective date: 05/2019 Review date: 05/2022

Legislation

Related documents

Appendix 1- 4AT 


Appendix 2 – MMSE

Appendix 2 – (continued)

Appendix 2 – (continued)

Appendix 2 – (continued)


Appendix 3 – RUDAS

 

 

Appendix 3 – (continued)


Appendix 4 – Kimberly Cognitive Assessment Tool

 

 

Appendix 4 – (continued)

Appendix 4 – (continued)

 

Appendix 4 – (continued)

 

Appendix 4 – (continued)

 

Appendix 4 – (continued)

Appendix 4 – (continued)

Appendix 4 – (continued)

Appendix 4 – (continued)

Appendix 4 – (continued)

Appendix 4 – (continued)

 

Appendix 4 – (continued)

Appendix 5 – 4AT Guide

 

 

 

 


Appendix 6 – PITCHED

 

Appendix 6 – (continued)

 


Appendix 7 – Delirium Treatment Pathway



Appendix 8 – Delirium Education Brochure (Metro North)

 



Appendix 9 – Education Escalator

DELIRIUM – EDUCATION ESCALATOR – Caboolture & Kilcoy Hospitals

 

SKILL LEVEL 1

SKILL LEVEL 2

SKILL LEVEL 3

STAFF

GROUP

AWARENESS LEVEL

 

All staff

 

DIRECT CARE – STAFF MUST DO

Appropriate clinical staff who:

  •                      meet all skill level 1 requirements
  •   are identified through the Performance and Development Planning (PDP) process (through work in clinical area)

SPECIALIST e.g. GLAD staff

Appropriate registered clinicians who:

  • meet all skill level 2 requirements
  • are identified through the PDP process and complete extra/ additional study.

STATEMENT

OF INTENT

 

 

Demonstrate awareness of knowledge to provide quality patient care in relation to cognitive impairment and delirium

Demonstrate application of knowledge to provide quality patient care in relation to delirium and actively participate in providing high quality care to patients with impaired cognition and/or delirium in their clinical unit

 

Actively promote an organisational quality improvement culture in relation to delirium assessment, management and prevention 

 

STRATEGIES

 

 

  • All staff be aware of Dementia/Delirium and how it may impact clinical and non-clinical contact with consumers and their loved ones.
  • New & existing Non-clinical staff to support consumers by directing concerns to appropriate clinical staff or upskilling relevant to their role.

 

  • New and existing relevant clinical staff:

 

       Identify there are delirium educational resources are on QHEPS

 

       Sign the self-declaration on this escalator 

 

  • Attend unit-based in-services
  • Demonstrate application of screening and prevention by actively assessing patient for

       Pain

       Infection (UTI’s)

       Thirst / constipation / hunger / malnutrition

       Environment – unfamiliar, noisy, disorienting, unsafe 

       Effects of medications / drug and alcohol withdrawal

       Boredom – lack of stimulating / diversional activities 

       Visual and hearing impairment

       Immobilisation due to physical restraint / use of equipment (e.g. urinary catheter, IV therapy)

       Urinary retention

       Sleep deprivation

 

  • Assist their line manager / the skill level 3 registered nurse/s with analysis of data and direct observations, and the implementation of quality activities
  • Facilitate utilisation and completion of the Behavioural Observation Chart (BOC) [or similar] and Behaviour Assessment and Management Plan (BAMP)
  • If practice or knowledge deficit/s attend delirium & dementia training. 
  • Sign the self-declaration on this escalator 

 

  • Actively support Caboolture-Kilcoy Delirium and Dementia Training programs and support implementation and evaluation of unit-based action plans to facilitate patient centred care

 

  • Oversee the activities of the skill level 2 direct care staff 

 

  • Actively champion implementation of the Delirium Clinical Care Standard from the Australian Commission on Safety and Quality in Health Care
  • Promote and educate staff on utilisation and completion of the Behavioural Observation Chart (BOC) [or similar] and Behaviour Assessment and Management Plan (BAMP)

 

  • In collaboration with the line manager oversee data analysis, the development, implementation and evaluation of unit-based action plans and quality activities
  • Sign the self-declaration on this escalator 

PERFORMANCE

INDICATORS

  • 100% of all relevant clinical staff will:

       appreciate that dementia/cognitive impairment and delirium are conditions they will have contact with whilst working in the health care environment.

       Appropriately escalate or question 

       sign the self-declaration

       Seek further knowledge as required into the future. 

  • 100% of clinical staff nominated to be skill

level 2 will:

       be able to provide to their line manager evidence of their activities in relation to the provision of quality care to patients with delirium 

       sign the self-declaration within 12 months of nomination

 

  • At least 2 clinical champions per clinical area will be nominated to be skill level 3 will:

       be able to provide evidence of their activities to their line manager and any relevant committee/s

       sign the self-declaration within 12 months of nomination

ACCOUNTABILITY

  • Line manager to monitor through the

PDP process

 

  • Line manager to:

       Monitor through the PDP process

       Maintain a database of skill level 2 clinical staff

       Communicate behavioural triggers and effective strategies at hand-overs, case conferences and document in medical records and clearly document DELIRIUM

       Educate patients / relatives about prevention strategies and access materials on QHEPS as require (confirm which forms).

  • Line manager to:

       monitor through the PDP process

       maintain a database of skill level 3 registered nurses 

 


DELIRIUM – EDUCATION ESCALATOR – SELF DECLARATION

 

SKILL LEVEL 1

SKILL LEVEL 2

SKILL LEVEL 3

EVIDENCE OF APPLICATION OF KNOWLEDGE TO CLINICAL PRACTICE

 

MINIMUM STANDARD

  • Orient patients to unit environment
  • Ask carer / family member about any recent changes in patient’s behaviour or thinking and how they have managed these changes.

Clinical Staff

  • Identify key risk factors such as:

       Age ≥ 65 years (≥ 45 years for Aboriginal and Torres Strait Islander peoples)

       Known cognitive impairment / dementia

       Severe medical illness

       Current hip fracture

       Recent anaesthetic or ICU admission

  • Conduct appropriate screening and prevention strategies (within scope of practice) to minimise the occurrence of behavioural triggers such as: 
  • Completion of 4AT with theflowchart (to be finalised) to guide practise.
  • Be aware of forms available to support management of patients and policies available at local level (i.e. GLAD admission procedure) and MNHHS wide to support care of this person.
  • Access and provide approved online education consumer factsheets on dementia/cognitive impairment and delirium to be accessed from QHEPS and provided to consumer and/or families/carers
  • Recognise gap in knowledge and need to upskill to provide high quality care for these consumers.

        Utilisation and completion of the appropriate BOC (including but not limited to PEEP/BOC/Mental Health visual observation chart) and BAMP as required

 

  • Provide updates to staff about best practice of the cognitively impaired person and promote utilisation of delirium screening per current policies and procedures
  • Upskill self through education and training and provide Knowledge on where to access resources e.g., Understanding Dementia MOOC, Dementia Training Australia modules, CH/MNHHS approved education modules
  • Actively support Nurse and Medical Education with relevant workshops and/or simulation/in-services.
  • Provide support to the skill level 2 staff 
  • Actively support and Role model and encourage staff to continuously use delirium, falls and pressure injury prevention strategies
  • Utilise Riskman reports, audit results and observations to guide activities
  • Oversee, in conjunction with the line manager, the development, implementation and evaluation of unit-based action plans and quality activities
  • Participate in activities such as:

       Research

       Benchmarking

       Root cause analyses

       Course development

       Policy and procedure development and review

When you have completed the following, give a copy of this document to your line manager / CN.

I believe that I apply, to my clinical practice, all the knowledge of a:

Skill Level   1       2       3   (circle the appropriate level)                              Date: ________________________   

 

Name: __________________________________________                          Signature: _________________________________________


Document history

Author

Caboolture Hospital, Delirium working group

Custodian

Chair, Comprehensive Care Committee. 

Compliance evaluation
and audit 

Evaluation on an individual basis as outlined within this document as a component of comprehensive care. This includes care and outcomes monitoring using the restraint form, behaviour chart and in-patient medication record.

Replaces Document/s

New Document

Consultation

Comprehensive Care Committee Members.

Marketing Strategy

Published on QHEPS, tabled at Comprehensive Care Committee for further distribution and included in monthly Policy and Procedure update in all staff newsletter.

Key words

Delirium; Cognitive Impairment; Care Pathways; Patient transfers; care continuity; transition; Risk Identification; 005202

 

 

 

 

 

Custodian Signature

Date

Julie Lahey, Chair – Comprehensive Care Committee, Caboolture and Kilcoy Hospitals and Woodford Corrections Health

 

 

AUTHORISATION

 

 

 

Authorising Officer Signature

Date

Dr Lance Le Ray, Executive Director and Director Medical Services, Caboolture and Kilcoy Hospitals and Woodford Corrections Health

 

The original signed version is kept in file at Service Improvement Unit, Caboolture Hospital