In my role as Clinical Lead for the Discharge to Assess service at Wilfred Geere, I review the newest NICE guidelines as they are released to see if there are any that are relevant to our service, and identify where improvements can be made to better meet the recommendations. Recently there was a guideline published around delirium – prevention, diagnosis and management, which was very relevant to what we do at Wilfred Geere.

Wilfred Geere Discharge to Assess service is a short-term residential unit for people who have been treated in hospital but need a period of time to assess their longer-term care needs before returning home or moving into longer-term care. Most of our service users may be diagnosed with an underlying dementia, acutely confused with delirium or have a combination of the two.

Delirium is a sudden onset of confusion that is often triggered by a change in medical condition or environment. It can cause temporary upset in a person’s mental state and independence that can last for days to months. Sometimes people never recover to the same level of function that they had before the illness.

The guidance made it clear that people are prone to delirium if they are aged over 65, have a previously known cognitive impairment (such as an underlying dementia), have a current severe illness or a recent hip fracture. It suggested that on transfer to a new care environment people should be assessed for these risk factors and flagged up if they are at risk. A review I did of our last 10 service users showed that they all had risk factors and most had more than one risk factor, so we are dealing with a population who are at high risk.

With regards to prevention of delirium, addressing any sensory issues, promoting nutrition and hydration and encouraging mobility were thought to be key. Our teams are already good at managing these issues- those who wear hearing aids and glasses are encouraged to use them, nutritional intake is monitored closely for the first 72hrs of admission and continued if there are concerns with clear pathways for when to raise issues, and our dedicated therapy teams see all new service users within 72hrs of admission (often sooner) to get them moving to the best of their ability. The environment also meets guidance, with clocks and calendars visible to reorientate people.

It also recommended that non-clinical staff were trained in recognising features of dementia in order to seek help from doctors accordingly. We realised that there was room for improvement here, and relevant information written by NICE was distributed to front-line care staff informing them of the key features to observe for. Wilfred Geere has tailored training for all staff provided by the council each year, and the manager has agreed that delirium should be a featured topic in the next round of training.

In our clinical meeting with our regular doctors we recapped diagnosis and management of delirium and common causes to consider, using the PINCH ME acronym
P: Pain
I: other Infection
N: poor Nutrition
C: Constipation
H: poor Hydration
M: other Medication
E: Environment change

We have taken the recommendations on board with regards to communication with relatives too, and have sourced some leaflets explaining delirium for patients and carers that are available for anyone who may want them.

Overall I am pleased that we were meeting most of the recommendations but have been able to make some changes that should improve the experience for those patients at risk of or living with delirium during their stay at Wilfred Geere.