DELIRIUM Bridging the gap in Doctors Education
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1 DELIRIUM Bridging the gap in Doctors Education Junior Claire Potter 29/01/16
2 Background Graduated QUB 2013 F1 NHSCT - Cardiology, Surgery, Medicine F2 SEHSCT - Psychiatry Old Age - Geriatric Medicine - A&E CT1 Psychiatry General Adult IP TNU
3 Why Delirium? Topical Common Poor understanding Prolongs admission Risk of Hospital acquired complications Impacts capacity
4 Audit 40 confused patients across four Geriatric wards in the Ulster Hospital Objectives - All patients are assessed for Delirium risk - All identified causes are treated - All delirious patients are reassessed - All pharmacological interventions are as per NICE guidelines
5 Results (1) 28 patients met criteria for Delirium (70%) n = 28 Obj 1 - All patients are assessed for Delirium risk No formal risk assessment took place AMT present in medical admission pack 19/28 completed 68% Obj 2- All identified causes are treated 100% Obj 3 - All delirious patients are reassessed 100%
6 Results (2) Obj 4 - All pharmacological interventions are as per NICE guidelines 3 patients required rapid tranquilisation 1 - safe and appropriate use of rapid tranq 1-4mg Lorazepam IM written as stat dose 1 2.5mg Haloperidol PO/IM in pt with Parkinson's
7 Outcome (1) Presented findings at Geriatric Teaching Feb 2015 Delirium Tool in development Risk Assessment Key area for improvement education of Junior doctors
8 Staff Survey 40 Medical and Surgical Staff surveyed Grades ranged from F1 Registrar Questions - List causes of Delirium - How confident are you in prescribing for the acutely agitated >65 - What would you prescribe as rapid tranq for the following cases <65 alcohol withdrawal, <65 acutely psychotic, >65 acutely psychotic, >65 Alzheimer's with UTI, >65 Lewy Body UTI
9 Staff Survey (2) List causes of Delirium
10 Staff Survey (2) How confident are you in prescribing for the acutely agitated >65 58%
11 Staff Survey (2) Prescribing scenarios <65 alcohol withdrawal, <65 acutely psychotic, >65 acutely psychotic, >65 Alzheimer's with UTI, >65 Lewy Body UTI
12 Staff Survey (3) 1 correct and appropriate prescribing review BNF, review guidelines Ring the Medics! Bleep the F1! Change Antibiotics 5mg Diazepam for all, 4mg Lorazepam, 4mg Lorazepam IV!!
13 Outcome (2) Delivered 2 focused brief teaching sessions Presented Poster at the I.C RCPsych June 2015 Difficulties of the Pharmacological Management of Delirium in the Elderly Joint Author in Foundation Years Journal 2016 An overview in the management of acute distress and agitation in patients over 65 Presented regional LPOP meeting Dec 2015
14 Teaching Ulster Hospital Antrim Hospital
15 Summary Delirium is a common condition that all MDT members should be comfortable diagnosing and managing Junior Doctors are often at first assessment Gaps in education and poor confidence when assessing Delirious patients needs to be addressed Local teaching opportunities NI Delirium Tool pilot
16 THANK YOU! Discussion Opportunities to improve education; local or regional? References Ward G, Perera G, Stewart R. Predictors of mortality for people aged over 65 years receiving mental health care for delirium in a South London Mental Health Trust, UK: a retrospective survival analysis. Int J Geriatr Psychiatry. 2014; 30(6):
17 Poster DIFFICULTIES IN PHARMACOLOGICAL MANAGEMENT OF DELIRIUM IN THE ELDERY International Congress of the Royal College of Psychiatrist 2015
18 Publication AN OVERVIEW IN THE MANAGEMENT OF ACUTE DISTRESS AND AGITATION IN PATIENTS OVER 65 Dr C. Potter, Dr K. Tang, Dr G. Young, Dr J. Anderson January 2016 Psychiatry edition
19 Delirium Tool
20 Teaching aids Reversible causes DELIRIUM Assessment ABC-DR D E L I R I U Dehydration/ Drugs Electrolyte imbalance Evidence of injury Level of pain Infection/ Inflammation Respiratory failure Impaction of faeces Urinary retention M Metabolic disorder A B C Asses risk Approach safely Background Basic investigations Clinical Examination Cardex D Documentation De-escalation R Reversible causes Risk Ax +/- intervention
21 Assessment MDT approach Risk Ax Kardex, Obs History CAM, 4AT 4 point AMT Abdomen
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