Barriers to completing the 4AT for delirium and its clinical implementation in two hospitals: a mixed-methods study

Abstract

Purpose To assess the clinical implementation and barriers to completing the 4AT for delirium in general medical and geriatric patients over 75 years upon admission to Wellington and Kenepuru Hospitals during the first eight months of 2017, 2018 and 2019. Methods Retrospective data from electronic health records were analysed using an explanatory-sequential mixed-methods approach. The initial quantitative phase measured doctors’ adherence to the 4AT and the rate of positive 4ATs (≥ 4). The subsequent qualitative phase identified doctors’ main reasons for omitting the 4AT through conventional content analysis. Results The quantitative population included 7799 acute admissions (mean age 84, 58.2% female). There was good clinical implementation of the 4AT, evidenced by an overall adherence rate of 83.2% and a rate of positive 4ATs of 14.8% that is in keeping with expected delirium rates in similar settings. The qualitative sample consisted of 875 acute admissions (mean age 84, 56.3% female) with documented reasons for omitting the 4AT. The main barriers to completing the 4AT were: reduced patient alertness, communication barriers (language, deafness, aphasia and dysarthria), prioritising patients’ wellness and comfort (addressing critical illnesses, symptoms, end-of-life issues and promoting sleep), pre-existing cognitive disorders, and unstructured delirium assessments. Conclusion Adherence to the 4AT was high and sustainable in both hospitals. Most barriers to completing the 4AT were potentially avoidable. Education about the 4AT in relation to these barriers may improve its implementation.

Positive scores on the 4AT delirium assessment tool at hospital admission are linked to mortality, length of stay and home time: two-centre study of 82,770 emergency admissions

“…The 4AT had positive score rates which were broadly consistent with estimated rates of delirium in the populations concerned. The present positive score rates are comparable with recent studies using the 4AT [ 46 ] and the Nursing Delirium Screening Scale [ 47 ] and contrast with the lower positive score rates reported in large scale studies using the CAM [ 15 , 18 , 20 , 21 ]. The study also has some limitations.…”

“…By contrast, in hip fracture care in England, assessment of delirium with the 4AT is mandated and incentivised as part of the Best Practice Tariff, and completion rates are >95% [ 27 ]. These and other studies [ 46 , 47 ] suggest that delirium assessment at scale in routine clinical workflow is possible but that achieving this requires appropriate data collection, and visibility, policy and education.…”

“…However, the CAM-positive rate in the sustainability phase of the study was 3.2%, markedly lower than the expected prevalence of delirium [ 1 , 4 ]. Other studies in large clinical populations have reported links between delirium and adverse outcomes, or rates of delirium assessment tool completion alongside positive score rates, but none has reported real-time delirium detection data from routine care in relation to outcomes [ 15 , 20 , 22 , 23 , 46 , 47 ]. By showing effectiveness in practice, the present findings provide helpful new evidence on implementation of delirium assessment for both clinicians and policymakers.…”

Delirium detection tools show varying completion rates and positive score rates when used at scale in routine practice in general hospital settings: A systematic review

“…Only three studies reported specifically on patients without a completed assessment. 18,21,22 In a study using the 4AT, patients without an assessment had similar outcomes to patients with probable cognitive impairment, 22 whilst in a study using the CAM, patients "unable to assess" had worse outcomes than patients with delirium. 18 This concerning observation highlights the importance of elucidating barriers to delirium assessment.…”

Delir in der Notaufnahme – ein unerkanntes Problem

“…Prinzipiell ist es zielführend, einen Test zu nutzten, der für die Notaufnahme validiert ist. Zusätzlich ist es sinnvoll, wenn möglich einen bereits in der Klinik implementierten Test zu nutzen, da sich die Performance eines Tests durch mangelndes Wissen oder andere Barrieren erhöht [23].…”