Guideline for the Identification and Management of Delirium (Including use of the THINK DELIRIUM Support Tool)

Transcription

1 Guideline for the Identification and Management of Delirium (Including use of the THINK DELIRIUM Support Tool) B27/ Introduction 1.1 Delirium is a common problem which occurs in about out of every 100 people admitted to hospital and also affecting up to 30% of all older medical patients and up to 50% of older adults undergoing surgery. 1.2 It is associated with increased morbidity and mortality with increased risk of institutionalisation on discharge. 1.3 Patients who develop delirium also have a longer length of stay and are more likely to develop hospital acquired complications such as falls and pressure sores. They are also more likely to develop dementia. Despite this, reporting of delirium is poor in the UK, indicating that awareness and reporting procedures need to be improved (NICE). 1.4 This document provides guidance to staff on the recognition and treatment of adult patients with delirium in line with NICE guidelines (excluding patients in Intensive Care Facilities). 2. Scope 2.1 This guideline is for use by all medical, Allied Health Professionals and registered nursing staff employed by UHL, including bank, agency and locum staff. 2.2 It applies to all adult patients presenting with an acute confusional state or where a delirium is suspected. Patients over 65 should be screened in line with NICE guidelines 2.3 Staff working on the Intensive Care Units within the trust should refer to the Consultant/Nurse in Charge of the unit for Guidance. The THINK DELIRIUM Support Tool is available as a useful reference tool. 3. Guideline Statements 3.1 It is the responsibility of the attending nurse or doctor to screen for a delirium by identifying whether the patient is more confused or withdrawn than their usual baseline. 3.2 If the initial screen is positive then the nurse and Doctor should refer to the THINK DELIRIUM support tool (appendix 1) and follow advice regarding investigations for a potential cause of delirium 3.3 Once a cause of the delirium has been identified then this should be managed appropriately. Where there is difficulty in managing the delirium then reference should be made to the General Management section of the THINK DELIRIUM support tool. 3.4 Any antipsychotic or sedative medication use should be restricted to those with dangerous or distressing symptoms. This should be used under supervision of a member of the medical team and reference to the THINK DELIRIUM support tool to ensure that the delirium has been managed appropriately. 3.5 The diagnosed episode of delirium should be clearly documented by the Doctor in the patient s case notes by use of the Think Delirium sticker, (appendix 2) if these are not available then it should be documented in the patient s case notes by hand. By documenting a diagnosed episode of delirium this prompts early recognition of future delirium episodes. Guideline for the Identification and Management of Delirium (Including use of the THINK DELIRIUM Support Tool) Page 1 of 6

2 3.6 Prior to discharge the THINK DELIRIUM Support tool should be referred to, to ensure that the community teams are aware that the patient has had an episode of delirium and if any follow up is required. The episode should be clearly documented on the ICE letter 4. Education and Training The THINK DELIRIUM Support Tool will be made available to all clinical areas. The Patient Experience Team will co-ordinate a Trust wide awareness raising campaign and also provide bespoke ward level training Ongoing education to all members of staff will continue as part of the Dementia category A and B training as well as tailored training for undergraduate and postgraduate medical staff, nursing staff and other users of the tool. The Frail Older Persons Advice and Liaison Service (FOPAL) will distribute copies of the tool and educational resources when reviewing all patients. 5. Monitoring and Audit Criteria Element to be Monitored Improved recognition of delirium Antipsychotic prescribing Improvement in Delirium coding FOPAL referral quality Delirium Sticker Audit Lead Method Frequency Dr Irfana Musa Dr Morgan/Dr Stoneley/Dr Musa Lara Wealthall/ Kerry Tebbutt FOPAL Kerry Tebbutt/ Dr Musa/Dr Stoneley Audit identification of delirium on ward bases Audit use of antipsychotics Audit discharge letters Audit referrals to FOPAL Audit of the use of stickers in those coded with a diagnosis of delirium Reporting arrangements Group 6. Legal Liability Guideline Statement Guidelines or Procedures issued and approved by the Trust are considered to represent best practice. Staff may only exceptionally depart from any relevant Trust guidelines or Procedures and always only providing that such departure is confined to the specific needs of individual circumstances. In healthcare delivery such departure shall only be undertaken where, in the judgement of the responsible healthcare professional it is fully appropriate and justifiable - such decision to be fully recorded in the patient s notes 7. Supporting Documents and Key References: UHL Mental Capacity Act Policy (Trust Ref B23/2007) UHL Deprivation of Liberty Safeguards Policy & Procedures (Trust Ref:B15/2009) Guideline for the Identification and Management of Delirium (Including use of the THINK DELIRIUM Support Tool) Page 2 of 6

3 UHL Policy for Assessment and Care Management of Patients At Risk of Wandering in the Acute Setting (Trust Ref: B25/2008) UHL Management of Violence, Aggression and Disruptive Behaviour Policy Including Restraint Guidance (Trust Ref: B11/2005) Guidelines for the Supervision and Management of Adult Patients with Agitated / Challenging Behaviour (Trust Ref: B6/2012) UHL CAM ICU Local Guidelines on Management of Delirium on the Intensive Care Unit UHL Dementia Care Pathway Guidelines (Trust Ref B1/2016) Delirium: Prevention, diagnosis and management 8. Key Words Delirium, THINK DELIRIUM, Confusion, Agitation, Aggression Author / Lead Officer: Dr Sarah Stoneley Dr Irfana Musa DEVELOPMENT AND APPROVAL RECORD FOR THIS DOCUMENT Approved by: Policy and Guideline Committee Job Title: Consultant Geriatrician and Clinical lead for Dementia Consultant Geriatrician Date Originally Approved: December 2008 Latest Approval Date: 3 February 2016 Policy & Guideline Committee Chair s approval Next Review Date: February 2019 Version Number: Details of Changes made during review: Greater focus on all age groups. 2 Guideline for the Identification and Management of Delirium (Including use of the THINK DELIRIUM Support Tool) Page 3 of 6

4 Appendix 1 Guideline for the Identification and Management of Delirium (Including use of the THINK DELIRIUM Support Tool) Page 4 of 6

5 Guideline for the Identification and Management of Delirium (Including use of the THINK DELIRIUM Support Tool) Page 5 of 6

6 Appendix 2 THINK DELIRIUM Date of admission: Cognitive Assessment score: Original diagnosis: Date of delirium onset: Presentation of delirium: Hyperactive / Hypoactive / Mixed (Please circle) Causes identified: Management plan: DOES THE PATIENT NEED A URGENT SENIOR REVIEW? Refer to Trust Think Delirium Support tool. Consider offering relatives a trust leaflet on Delirium Continue to monitor for risk factors for delirium Document delirium on the discharge/ice letter and relevant information for GP. Guideline for the Identification and Management of Delirium (Including use of the THINK DELIRIUM Support Tool) Page 6 of 6