Belmont District Hospital implemented an education package for nursing staff, to improve the use of the Confusion Assessment Method (CAM) screening tool in the emergency department (ED). The CAM tool is an affordable and easy way to dramatically improve the outcomes of patients presenting to the ED with delirium.
Aim
To ensure 80 per cent of patients over the age of 75 who present to Belmont District Hospital ED with delirium, have a CAM sticker added to their file.
Benefits
- Improves delirium screening rates of older people who present to the ED with confusion.
- Improves the timeliness of delirium diagnosis and treatment in older people.
- Prompts nursing and medical staff to ask questions about what is ‘normal’ for the patient, which can trigger the Delirium Pathway.
- Enhances collaboration with staff, patients and carers.
- Reduces unnecessary hospital admissions and length of hospital stay.
- Reduces the risk of delirium symptoms, such as aggression and injury from falls.
- Reduces healthcare costs associated with treating late-stage delirium.
Background
Delirium is a common neuropsychiatric syndrome in older people, characterised by confusion and inattention. It can lead to aggression, injury from falls, hospital admission and a lengthy hospital stay, early admission to a residential aged care facility, an increased risk of morbidity and mortality, and increased healthcare costs for the patient and the healthcare system.
More than 30 per cent of older people who go to hospital in NSW experience confusion during the admission process, usually as a result of dementia and delirium1. While delirium can easily be treated if detected early, it is considered a medical emergency and requires screening and treatment as soon as possible. However, cognitive screening for older people is often overlooked during the admission process, which can lead to an assumption that any confusion experienced by the patient is a result of dementia. As a result, a diagnosis of delirium is often missed2.
An audit conducted at Belmont District Hospital in April 2017 found that only nine out of 60 patients over the age of 75 were screened for delirium when they presented to the ED. Of the people who were not screened, many were discharged with a diagnosis of confusion, with no further screening or treatment recommended. A staff survey conducted in April 2017 also showed a lack of understanding of the CAM screening tool, which led to poor use of the sticker and high rates of undiagnosed delirium in the ED.
Implementation
- Education on the use of the CAM screening tool was delivered to nursing staff in the ED. It was delivered via a series of face-to-face sessions over three weeks, during periods of low activity.
- A regular auditing schedule was established, to measure the use of the CAM screening tool in the ED. Audits were scheduled bi-annually and undertaken by a delirium champion.
- Face-to-face education on the use of the CAM screening tool was delivered to nursing staff in the ED by the aged care services emergency team nurse.
- A PowerPoint presentation was updated based on previous delirium education. It incorporated a recent patient story and was presented twice during the project, at morbidity and mortality meetings for ED staff.
- Moving forward, staff will be encouraged to complete online delirium education modules located in My Health Learning, to improve their understanding of delirium. Emails to staff and promotional posters in the ED will be used to remind staff to complete the training. The nurse unit manager will enforce compliance and relieve staff in the ED during periods of low activity, so modules can be completed during work hours.
Status
Sustained – The project has been implemented and is sustained in standard business.
Dates
March 2017 – December 2017
Implementation site
Belmont District Hospital, HNELHD
Partnerships
Clinical Excellence Commission. Clinical Leadership Program
Results
An audit of 60 patients over the age of 75 years was conducted in April 2017. It showed that 15 per cent of patients had received delirium screening in the ED. The audit was repeated following implementation of the project, to determine any improvements in the use of the CAM screening tool. The results of the November 2017 audit showed the number of patients screened for delirium increased to 43 per cent. While the aim of 80 per cent was not achieved, the project forms a strong foundation on which to base future Plan Do Study Act cycles.
Lessons learnt
- It is important for the project leader to delegate tasks, so they can oversee the process and keep the team on track.
- It can be difficult to navigate personality and work style differences, however overcoming this challenge is critical to the success of the project.
References
- NSW Agency for Clinical Innovation. Care of Confused Hospitalised Older Persons [Internet]. Chatswood NSW: ACI; 2018 [cited January 2018].
- NSW Agency for Clinical Innovation. Care of Confused Hospitalised Older Persons: Undertaking Cognitive Screening [Internet]. Chatswood NSW: ACI; 2018 [cited January 2018].
Contact
Marcia Ingles
Clinical Nurse Specialist – Emergency
Belmont District Hospital
Hunter New England Local Health District
Phone: 02 4923 2000
Marcia.Ingles@hnehealth.nsw.gov.au
