This document is a summarised version of OP-GC1 Clinical Handover, OP-CC5 Hospital Patient Transfers , OP-GC1 Patient Identification & OG-GC2 Delirium Guidelines The summary has been created to combine best practice information into one document specific to the Emergency Department, and has been endorsed by the ED Leadership Team. Staff should review the above PPG’s if they require further information.
Delirium is a serious medical condition linked to serve morbidity and mortality. Affects include increased length of stays, falls, increase risk of death, development of dementia & admission to a residential care facility. This QRG will provide staff with an overview of the management within the Emergency Department.
A disturbance of consciousness and a change in cognition that develops over a short period of time. That is a transient cerebral dysfunction, resulting in acute decline of attention & cognition. Presenting itself as either hyperactive, hypoactive or mixed.
This QRG applies to all presentations to the Emergency Department.
It is the responsibility of the Nurse Unit Managers and Directors of the Emergency Departments of each site to ensure the relevant staff are familiar with this QRG, that it is implemented according to the guidelines as outlined within, and that there is compliance by all staff members.
Hyperactive: Agitation, increased vigilance, hallucinations. Can sometimes present as psychotic symptoms.
Hypoactive: Lethargy & reduced psychomotor functioning. Often missed.
Mixed Delirium: Here patients will move between hyperactive & hypoactive delirium.
Terminal Delirium: often occurs in the dying person & may present as anguish, restlessness, anxiety & agitation.
First line of treatment followed by pharmacological management when all non-pharmacological management has failed & the patient is becoming more distressed or shows an increased risk to themselves or others.
Antipsychotics and benzodiazpines do not treat delirium. They work on the symptoms & should not be used to reduce a person’s wandering or calling out behaviors.
Remember to monitor & document patient’s response regularly, Behaviors of concerns, GCS & complete all nursing risk assessments on EMR and back of nursing chart.
| Clinical Factor: | Strategy: |
| Orientation | o Provide appropriate lighting and clear signage. A clock and calendar should also be easily visible to the patient at risk.
o Regular verbal orientation & reassurance. o Encourage the family/carers to visit when the patient may be distressed during the day (if known) so as to provide support and reassurance and in providing orientation and reassurance to the patient. |
| Behaviours | o Regular monitoring (TDS) for changes in behaviour, cognition and physical condition.
o Repeat 4AT if changes noted and start behaviour chart. o Avoid the use of mechanical restraint. o Provide activities for stimulating cognition if appropriate e.g. reading material, engage patient in meaningful, stimulating conversations and activities. o Ask family to bring familiar items from home (e.g. photos, dressing gown). |
| Bowel and Bladder | o Check bladder scan and monitor for signs of retention.
o Check for urine infection-FWT. o Commence a bowel chart, highlight and treat any constipation. o Maintain continence – toileting regime. |
| Hydration and nutrition | o Avoid malnutrition and dehydration.
o Fluid balance chart. o Encourage the patient to drink. Consider subcutaneous or intravenous fluids if necessary. o Assist with oral intake (red dome). o Minimise interruptions at mealtime. o Involve family / carers in mealtimes including provision of food to patient’s preference. o Referral to Speech Pathology if needed. |
| Mobility | o Encourage mobility.
o Consider assistive aids (bed alarm, low-low bed). o Optimise safety if patient is wandering. o Referral to Physiotherapy and Occupational Therapy if needed. |
| Falls and pressure care | o Falls minimisation strategies as per risk assessment (gait aids, footwear, call bell in reach, reduce clutter, bed brakes).
o Pressure injury prevention strategies as per risk assessment. |
| Infection | o Look for and treat infection.
o Avoid unnecessary catheterisation. o Implement infection control procedures. |
| Hypoxia | o Assess for hypoxia and optimise oxygen saturation if necessary. |
| Medications | o Review medication list to identify medications which can decrease cognition and increase confusion. |
| Pain and discomfort | o Assess for pain. Monitor non-verbal cues.
o Commence and review for adequate pain management in any patient whose pain is identified or suspected. o Avoid unnecessary invasive devices (urinary catheter, cannula etc.). |
| Hearing and Visual impairment | o Resolve any reversible causes of the impairment (such as impacted ear wax).
o Ensure working hearing aids and glasses are available and used by those who need them. o Refer to Audiology and/or Speech Pathology if necessary. |
| Environment | o Avoid bed moves.
o Bed in visible area. o Lighting appropriate to time of day. o Encourage family/carers visiting. |
| Communication | o Introduce yourself and your role.
o Keep information/explanations simple. o Involve family/carers to assist with identifying patient’s values and complete “About Me “form. o Involve families / carers in the provision of care, decision-making and future care planning. o Provide the family with a delirium brochure and information about delirium. o Minimise number of staff involved. o Use interpreters for patients from CALD background. o Referral to Speech Pathology if needed |
| Sleep Disturbance | o Aim for a normal sleep-wake cycle.
o Avoid nursing or medical procedures and medication administration during sleep. o Reduce noise to a minimum during sleep periods. |
OP-CC5 Hospital Patient Transfers
| Title: | Managing Delirium within the Emergency Department | |
| Version: | 2.0 | |
| Date Published: | August, 2021 | |
| Date of scheduled review: | March 2024 | |
| Author: ED Leadership Team | Approver: ED Leadership Team | |
| Reviewed By: Ian Law | Date: March 2023 | |
