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Foundation of Nursing Studies Project Report
Critical to Care
Improving the care to the acutely ill and deteriorating patient
Keywords
Delirium, Relatives, Person Centred, Communication, Confusion.
Duration of project May 2010 – January 2011
Southampton University Hospital NHS Trust
Project Team Leader
Karen Hill, Acuity Practice Development Matron
Contact
02380795138
07826858944
Project Team
Clare Tull HPB Support Sister Surgical Unit
Chris Moffat Sister Acuity Link Nurse E5
Lindsay Knights Staff Nurse Acuity Link Nurse E5
Tracy Watts Associate Nurse Practitioner Assessment E5
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Summary
Within the adult acute care hospital it is a recognised skill to be able to assess through
quantifiable physiological measurements the acutely ill and deteriorating patient. Current
national guidance (NICE, 2007) outline the clinical skills required in assessment and recognition
of the acutely ill adult patient. However within paediatrics and mental health institute, much
greater attention is paid to the more qualitative measures of feedback from relatives or
individuals that know the patient, in relation to their social behaviours, physical function,
perception and cognitive function. These in themselves can be subtle changes to identify but
which can be key antecedents to the sick and deteriorating patient prior to clinical physiological
measures changing.
The concept of the ‘Critical to Care’ project was introduced to alert nurses to early deterioration
in adult patients prior to clinical physiological changes in observations, through listening to
relatives or close acquaintances of patients who had identified subtle alterations to the patient’s
behaviour, physical function, perception or cognition.
Practice development methods and approaches were used and enabled a positive outcome
from the ‘Critical to Care’ project. There were several challenges that the project team faced
along the journey of the project, however the tools adopted enabled the team to pre-empt
occurrences and overcome issues.
On reflection, the initial work focusing on understanding the culture and context of the ward,
the values and beliefs of the staff, facilitation styles and identifying and involving stakeholders
from the outset, enhanced the action plan of the project and assisted in making the outcomes of
the project positive for staff, patients and the organisation.
Initial data demonstrates a benefit in outcome to patients through early alerting of potential
deterioration based on social, psychological and behavioural changes; enabling early treatment
and intervention and preventing physiological deterioration. By using a practice development
approach this project changed from merely being a project that instructs staff to do a task to an
all encompassing project that has positively developed understanding in how the nursing team
work, why the nursing team work in certain ways, what the nursing team value and what
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influences their work. The learning for the team is that they will use similar tools and techniques
to enable other practice changes and will always aim to put the Patient First.
Aim of project
To develop a patient centered framework for staff to identify the early deterioration of patients
through the monitoring of their cognitive, perception, physical function and social behaviour.
Objectives
• To develop a model of care in partnership with the relative or significant individual to
recognise changes in cognitive, perception, physical function and social behaviour in the
patient
• To develop the skills of staff through education, to enable the early detection of the
deteriorating patient using an assessment of cognitive function, perception, physical
function and social behaviour
• To test and evaluate the model in clinical practice
• To make recommendations for future practice
Context of Care at SUHT
Southampton University Hospital NHS Trust (SUHT) is a university teaching hospital situated in
South Hampshire. The Trust has 112,000 patients per year and provides hospital services to 1.3
million people. It is a major centre for teaching and research.
The Emergency Surgical Admissions Unit is one of six surgical wards within the surgical division
at SUHT. The unit has recently been altered from a combined gastroenterology, hepatology and
acute surgical admissions ward, to providing care for surgical emergency admissions only. The
24 bedded ward comprises an additional four trolleys within an assessment and triage area.
The recognition and reporting of delirium within an acute ward environment was observed by
the nursing acuity teams within the surgical directorate as an area for development. This was
also acknowledged by the Strategic Acuity Group within the hospital trust as an area for
monitoring and audit. As part of the acuity team monitoring deterioration within the unit,
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various solutions and alternative methods for identifying patients at risk of delirium were
devised and presented to the relevant stakeholders.
The project team at ward level initially comprised two Band 6 nurses, one Band 6 from the
admissions unit and a staff nurse who was part of the acuity link team within the ward. The
remaining Band 6 nurse was completing a secondment monitoring acuity issues within the
surgical division. Other stakeholders joined the project through its development.
A successful application to the Patients First Programme at The Foundation of Nursing Studies
(FoNS) and the Burdett Trust enabled the development of a pilot project focusing on improved
identification and communication for patients experiencing delirium within the Emergency
Surgical Admissions Unit
Background
Since the introduction of Modified Early Warning Scoring system (MEWs) as the aggregated
track and trigger system of choice within the trust it has assisted in identifying the early
deterioration of critical illness. However, the standard of recording and reporting has not
demonstrated the 100% compliance which is stated within the hospital trust protocols and
recommended by The National Patient Safety Agency (2007).
The ward had recently undergone restructuring of clinical speciality, changes in staffing
compliment, high levels of temporary staff resulting in a team that recognised itself to be lacking
in energy, under resourced and losing its focus. In addition some relative/patient complaints on
the ward had highlighted that relatives had informed staff of their relative deteriorating;
however these concerns had not been acted upon.
The National Confidential Enquiry into Patient Outcomes and Death (NCEPOD) (2005) discussed
how ward staff failed to recognise the significance of identifying those patients within an acute
environment who have the potential to deteriorate. However, Lord Darzi (Department of
Health, 2008) purports the basics within health care provision should be right, first time, every
time. The ability to do the basics better within recognition and reporting is a key factor to
improving patient safety and promoting higher standards of accountability for nursing staff.
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Project Methods and Approaches
A number of practice development methods and approaches were used for the ‘Critical to Care’
project acknowledging that understanding a practice problem is challenging and implementing
change or getting evidence into practice can be a complex process.
The project consisted of four main phases:
1. Project Facilitation
2. Assessment of Context and Culture
3. Action Planning
4. Evaluation
The first three phases will be outlined below, before further details about the processes
involved in the project are provided. The evaluation phase will then follow.
Phase 1. Project Facilitation
To provide foundation to the project, the project team met to develop their understanding of
the purpose of the project, the methods and approaches to be used, to outline the factors that
would help the team in achieving the project and finally the values and beliefs the team had in
relation to practice development. A values clarification exercise (Warfield and Manley, 1990)
was used to achieve this. This enabled the team to come together to discuss the purpose of the
project and to outline factors which they felt would help in achieving the project aim or detract
from the end goal.
An awareness of individual and team facilitation styles was needed to provide the team with
intelligence regarding which characteristics individuals adopted when working with teams. The
team used the model of situational facilitation (Hersey and Blanchard, 1996) as a tool to identify
and discuss their preferred styles of facilitation. Overall the team displayed a balanced
situational facilitation style with characteristics being spread across all domains (encouraging,
supporting, coaching and directing). However the exercise demonstrated that certain individuals
were more dominant in one style than another and therefore they were given roles within the
timeline of the project that suited their natural style.
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In addition, the project team spent some time discussing Heron’s six categories of intervention
to examine their knowledge and skills of the authoritative and facilitative interventions. This
provided a focussed understanding of the six intervention categories and fostered an awareness
of when each intervention would be beneficial when facilitating the project.
The team set aside an hour to foresee the perceived impact of the project from a patient, staff,
organisation and stakeholder perspective. This group work assisted the team in starting to
develop an evaluation framework.
A stakeholder analysis was used at the outset to identify the stakeholders in the project, and
their status, level of collaboration and participation in the project. This supported the team in
weighing up the influence, level of interest and consequences of investment in that
individual/group to the outcome of the project. The group were surprised by the number of
stakeholders which needed to be included during the project plan – fourteen in total.
Having identified the stakeholders and their level of involvement and influence the team
entered into some creative thinking on how to engage with the individuals to ensure they had
opportunity to participate in the project. A range of methods of communication were developed
from written memos, coffee meetings, lunch meetings, emails, attendance at staff meetings,
verbal discourse and 1:1 opportunities.
The work around how to facilitate the project provided the team with an understanding of the
need to set out a clear project plan. The work so far highlighted that what had initially been
perceived as a simple practice development project was far more complex than initially viewed.
The recognition of a larger group of stakeholders and their influences coupled with the
timeframe of the project, reinforced the need for a clear project plan to facilitate group
cohesiveness and the achievement of target milestones.
Phase 2. Assessment of Context and Culture
An understanding of the culture and context is key to developing and sustaining practice change
(Rycroft-Malone et al., 2002). To assist with developing an appreciation and understanding of
the context of the ward, the project team and ward staff used the Context Assessment Index
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(CAI) (McCormack et al., 2009). The objective was to assess whether the ward was conducive for
person centred practice and the receptiveness of the ward to change and develop. Analysis of
the CAI identified that overall the ward scored low on:
- A proactive approach to care
- Staff have explicit understanding of their own attitudes and beliefs towards the
provision of care
- Patients are encouraged to participate in feedback on care, culture and systems
- Patients are encouraged to be active participants in their own care
This illustrated the contextual areas the team agreed were weak. The team used this
information to develop an action plan that focussed on addressing these weaknesses.
Phase 3. Action Planning
The action planning phase of the project provided a systematic approach to the project design
and provided the opportunity to undertake a literature and evidence review. Patients and
relatives were asked to inform the design and provide feedback on ideas which the project team
had developed. This feedback was gained by speaking with patients and relatives who had
experienced being an inpatient on the ward area. A forum was arranged, away from the clinical
ward area to gain an insight from their perspective of their experiences and how these could be
improved. The work which had been undertaken on culture and context informed the action
plan, allowing time for the development of ward values and beliefs, utilisation of nurse’s
experience in other areas, developing transformational leadership. Previous work on enablers
and perceived barriers informed the action plan by focusing thoughts on the professional,
strategic, organisational, social and personal elements of the stakeholders towards the project
and influences on the design.
The Project
Initially the project centred on the deteriorating patient, identifying a method for relatives and
or significant others to communicate their concerns about the deteriorating cognitive function
of a patient. A notice board was situated at the entrance to the ward to publicise the project,
allowing high visibility to all visitors. Relatives and patients were invited to fill in a concern form
and place it in a confidential communication box on the ward desk. The concern form was to
highlight to staff any concerns they had in regard to changes in their relative’s behavioural,
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psychosocial or cognitive function This box was emptied on a daily basis by one of the project
team.
A Tree of Knowledge was devised as a pictorial representative of the development and growth
of knowledge. It was situated within a visible allocated board in the ward. Comments which
staff, relatives and patients had made were hung onto the tree by the project team. The
purpose of this tree was to visually display to visitors, ideas they had or queries regarding
general aspects of care. The ward staff were informed of the Critical to Care pilot project
through ward meetings and were involved in the distribution of the comment cards.
It was recognised by the project team after four weeks, that the concern forms did not highlight
information regarding patient’s deterioration in cognitive function but were centred on other
issues, such as visiting times and patient care. The team recognised these were valid concerns
and highlighted the issues to the ward management team. This process refocused the project
team towards the objectives of the practice development project.
The project team regrouped to look at the values clarification and aims of the project. Informal
discussions with in-patients elicited that some patients were unaware of which nurses were
caring for them. To address this issue a board was situated outside each bay within the ward to
display the name of the nurse responsible for the delivery of care in the designated area each
day.
The project team provided the ward with information on the ward staff structure and a photo
board to recognise all the team members on the ward; this included nursing, administration and
housekeeping staff. The ward received positive comments regarding these changes.
Patient Support Group
A patient group meeting was arranged, to discuss the project with patients and relatives away
from the ward environment. The meeting was facilitated by the project team.
The meeting was conducted in a non clinical area that provided a relaxed and informal
atmosphere. Lunch was provided and all participants were offered free parking. Ex patients of
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the ward and patient support groups for surgery were invited to attend the meeting by the
Patient Advisory Liaison Service.
The patient group were introduced to the project team and a presentation was given outlining
the project aim. The meeting was opened up to discussion relating to patient and relative
experiences of the ward and the care that they received. The discussions provided themes and
information which were invaluable to informing the project further.
The group identified the first twenty four to forty eight hours after admission as the most
stressful and frightening for them and for their relatives. The importance of good
communication and reassurance continued to be mentioned by the entire group with one
member highlighting the Assessment Area within the Admissions Unit as a priority, as it was the
first introduction to the hospital for many patients. The group member noted how fellow
patients without a relative or significant other with them appeared to be at greater risk of poor
communication as they had no advocate for them.
This highlighted to the project team an area they had not considered and could now incorporate
within the project.
From the meeting the following plans were initiated:
• The Nursing Associate Practitioner from the Ward Assessment Area would be invited to be
involved in the project group
• A patient questionnaire was created to be used in the Ward Assessment Area to establish
the communication needs of patient and relatives on admission
• The development of a Patient Concern Card System to be discussed with PALs and the
senior nursing teams within the unit
A meeting was held at ward level with the Nursing Associate Practitioners who worked within
the Assessment Area. The staff that were interested in becoming involved and assisting with the
project team developed a short questionnaire for the relatives and patients to complete within
the Assessment Area.
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The aim of the questionnaire was to open up communication between staff, patients and
relatives. There were fourteen closed questions with a comment area for individuals to expand
upon the questions. The questionnaire was devised from the comment cards as the comment
cards were open for the volunteer’s comments, the questions were more direct. Over a four
week period, the questionnaires were given to all patients and relatives who arrived in the
Assessment Area and needed to be admitted to the main ward. They were distributed by the
Associate Practitioner (Band 4) and Health Care Assistants (Band 2-3). A total of thirty-five
questionnaires were distributed, thirty were completed and returned. The questionnaires were
analysed by the project team at the end of the four week period.
A recurrent theme of the need to improve communication between patients, relatives and
hospital staff continued to appear.
The project team considered the questionnaires would have a greater validity if they were
completed after the patients were admitted to the ward. They were completed with the patient
and relatives by a member of the nursing team caring continuously for the patient.
Thompson and Dowding (2004) note intuition and expertise are important factors in decision
making when combined within a strategy of choice for the patient. Therefore nurses who are
caring for the same patient group over a period of time can identify subtle changes in their
patients, especially if that care has been provided since admission.
A Patient Concern Card was initiated so that if relatives had concerns regarding the patient’s
deteriorating condition and felt this was not recognised at ward level they could contact the
surgical bleep holder who could review the patient and ensure the ward initiated a plan of care.
The cards were devised with assistance from the Patient Advisory Liaison Service and the project
team. It was anticipated that the cards would encourage contact at ward level first then to a
senior nurse review. When the plan was presented at the senior nurse meeting which comprises
Band 6 and 7 nurses and Matrons, the idea was not considered feasible. The following reasons
were cited:
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• The cards were thought to be misleading and would be interpreted as a negative
perspective on the care provided at ward level
• The potential for an increase in the bleep holder’s workload which would only work if
more resources were available within the current bleep holder’s role
Following this meeting the project team met with the project leader and the FoNS facilitator to
clarify the aims of the project, correct misconceptions and establish a framework to monitor and
identify the patients with early stage delirium. This was a pivotal part to the project as the
project team recognised that the project had become blurred and required refocusing back to
its aims and objectives.
The project refocused to its initial intentions; to establish a framework where staff could
interact with patients and relatives to collect information in establishing if a patient was at risk
of deterioration by identifying the subtle changes presented by delirium. Research has
demonstrated that older people who are medically unwell often develop delirium (Marcantonio
et al., 2005) and that up to 29% of people diagnosed with dementia were misdiagnosed and
actually had delirium (Farina et al., 1999). It has been estimated that the prevalence of delirium
is as high as 60% in hospitalised older people on medical and surgical wards (Amador and
Goodwin, 2005). As a person with delirium may become extremely unwell and develop
complications such as pressure sores and pneumonia (Brown et al., 2002) and as the onset of
delirium unlike dementia is usually rapid with a deterioration in days (Nazarko, 2005) it was
agreed by the project team that the focus for the project would change.
With the refocus on the original aim it was agreed to arrange some teaching sessions at ward
level with lunch provided to encourage all level of staff to attend. These were to educate front
line staff in relation to Dementia/Alzheimer’s disease and delirium. The teaching sessions were
in accordance with the National Institute for Clinical Excellence (NICE, 2010).
Following staff teaching, posters were developed and ordered for each of the ward bays and for
the project information board asking relatives to inform ward staff of any specific changes
described in the poster. The poster contained the details of who to contact on the ward if they
were concerned about their relative.
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A Delirium Log was devised to capture data on all patients that were assessed by nursing staff
with potential or actual delirium. This contained the date and time of admission, date and time
delirium was first reported, whether the patient had an activating MEWs score or change in
their neurological status and what action had occurred following the episode of delirium.
The project team were able to log the number of patients who had been admitted to the
Admissions Ward who were displaying significant signs of delirium but had not activated MEWs.
To the project team these were the patients who were considered at high risk of being
overlooked in accordance with delirium. Others who were also identified as being at high risk
were individuals who had no family or visitors as it was deemed subtle changes in behaviour
would be unrecognised.
The delirium log was linked alongside another tool which had recently been implemented within
the trust called the Turnaround Project; approval was obtained from Clinical Governance to use
the Critical to Care recognition symbol. The Turnaround Project is used with those patients who
are identified at high risk of developing pressure sores and falls. Each individual who is placed on
the Turnaround Project has either a card with a falling star or a cushion placed at the end of
their bed; this requires nursing staff to be proactive every two hours in assessing the patient’s
requirements. The patients with delirium were identified by an asterisk symbol at the end of
their bed; this symbol was also added to the nurse’s handover sheet to enable recognition of
these patients at risk during verbal handover between staff. The staff were more accepting of an
incorporated project rather that additional paperwork to complete.
Nursing staff were all given pocket laminated cards describing the Critical to Care project with
each card giving a brief description of delirium and an outline the aim of the ward to identify
patients with delirium. The card emphasised the need for good communication between
patients, carers and health care professionals.
Phase 4. Evaluation
The project team invested time into exploring how they would know the project had been
successful; but not only from their perspective but that of the patients, relatives, staff and other
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stakeholders. Time was spent reviewing the aims and objectives and the overall intention of the
practice development.
Two types of data were used to inform the evaluation; quantitative and narrative. These will be
outlined below.
Quantitative Data
The Delirium Log was commenced in November 2010 and completed in January 2011. The data
was collected by the project team through discussion with the Emergency Admission nursing
team and the associate practitioners within the Assessment Area. The nursing team were
encouraged to identify those patients they had assessed as experiencing episodes of delirium
and also to document any family concerns regarding change in behaviour, disorientation or new
confusion discussed with them.
Twenty patients were identified within the delirium criteria, 11 patients were admitted by the
surgical Assessment Area and 9 were medical transfers. The medical patients were transferred
to the Emergency Admissions Unit because of severe winter pressures within the Trust. This
data provided unexpected information to the project that had a positive effect on the
understanding of delirium in patients with dementia.
The seven patients that were highlighted by family members as experiencing delirium were also
noted to have a change in their normal behaviour. The main carers could identify these subtle
patterns which could have been missed by nursing staff. The majority of patients were identified
by the ward nurses with one patient in the Assessment Area demonstrating signs of delirium
following their initial admission and assessment.
The following tables demonstrate which patient groups were recorded:
How patients with delirium were identified
Identified by nurses Identified by family/carer Identified in Assessment Area
12 7 1
14
Patients at risk of further deterioration
Activating MEWs 3
CNS recorded 11
Medical High Care Transfer 1
Over the last six months there appears to have been further evidence to demonstrate the
positive aspects of this project to recognition of the deteriorating patient prior to clinical
physiological changes in observations. Twelve patients which have been recognised by the
nursing staff as having a change in their behavioural or psychological state, following discussions
with their family have gone on to later display clinical deterioration and require admission to
high care, theatre or level three facilities. The behavioural and psychological changes identified
whilst previously not being considered as significant, heightened the nursing staff’s awareness
of these patients and led them to increase their visual observations.
Narrative Data
Narrative data was collected from the staff during staff meetings. The staff felt that:
‘we feel that we call the doctors earlier now – sometimes you don’t know what is wrong
with the patient but you can explain how their concentration has changed, or they have
become withdrawn’
Assistant Practitioner 1
‘It’s great because it’s brought back the art of nursing……it’s OK now to talk with the
patients and relatives. It is an aspect of caring and assessment that previously has been
eroded because the ward is busy and hectic….’
Staff Nurse
Recent discussions on the ward have highlighted that the staff feel more engaged in talking to
patients/relatives and listening to what they are saying.
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From the relative’s perspective there have been positive outcomes from the project. Comments
were collected from the relatives who had previously experienced the service and were part of
the project’s relative/patient group.
‘You feel that the staff have time for you … they ask questions that the doctors don’t
always ask…. And you feel are insignificant to tell the doctor but it’s really worrying
when your husband is acting completely out of character…nothing obvious if you didn’t
know him but to me he was acting differently to normal’
Relative C
Conclusion
The overall data from the project indicated patients identified with delirium can develop signs of
further deterioration and that both nursing staff and carers/relatives can be active participants
in recognising and preventing or reducing the deterioration, which if treated earlier may prevent
escalation of care.
The Critical to Care project has been a major challenge due to the continual changes and
restructuring that took place within the Emergency Admissions Unit. The project has been
through different stages in the process of establishing the framework for delirium identification
and reporting. Although this has been frustrating, the positive elements the team have
contributed to the ward area have been rewarding.
The ability to keep the project team and plan together through this adversity has given all
members of the project team an understanding of how difficult it can be to implement a
development in practice and keep momentum within a project. Overcoming these challenges
and developing a patient centred approach to recognising delirium has been invaluable. The
sustainability of the project within the surgical unit will be the next goal to achieve.
The practice development methods and approaches supported all the elements of the project in
addition to providing a proven strategy for the project team to use as a guide to assist in the
development of the practice change. These approaches not only enabled the development of
the project but also improvement in the skills and abilities of the project team which can be
utilised for future projects. The project team specifically developed their skills in identifying
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stakeholders and encouraging critical reflection. Understanding the role of values and beliefs
clarification assisted the project team in enabling inclusion of all those involved. From a ward
perspective, examination of the workplace culture and context enabled a focus on a patient
centred approach.
The opportunity to use practice development methods and approaches that the project team
were introduced to by the ‘Patients First’ programme, clearly supported them throughout the
project. The programme kept the team focussed and when they verged off line it brought them
back to the intentions of the project. The project team truly believe that the success of this
project was underpinned by the mantle of practice development, and the opportunity that we
were afforded through the Foundation of Nursing Studies/Burdett Trust for Nursing to support
and guide our work and putting our ‘Patients First’.
Recommendations
• Rollout of the delirium log and symbol cards throughout the Surgical Unit
• Present the finding of the pilot study to Trust Governance
• Develop the recognition of delirium to be included within the MEWs activation system
• incorporate study sessions on identifying delirium within preceptorship course and
mandatory study days within the Trust
• Share and disseminate of project nationally
REFERENCES
Amador, L.F. and Goodwin, J.S. (2005) Postoperative delirium in older patient. Journal of
American College of Surgeons. Vol. 200. No. 5. pp 767-773.
Barrett, C., Angel, J., Gilbert, M., Bouras, C., Thompson, K., Singleton, E. (2005) Systematic
processes for successful sustainable practice development. Practice Development in Health Care.
Vol. 4. No. 1. p 5-13.
17
Brown, T.M., Boyle, M.F. (2002) ABC of psychological medicine: Delirium. British Medical
Journal. Vol. 325. pp 644-647.
Cioffi, J. (2000) Recognising of patients who require emergency assistance: a description study.
Heart Lung. Vol. 129. No.4. pp 262-268.
Marcantonio, E.R., Kiely, D.K., Simon, S.E. (2005) Outcomes of older people admitted to
postacute facilities with delirium. Journal of the American Geriatric Society. Vol. 53. No. 6. pp
963-969.
McCormack, B., McCarthy, G., Wright, J., Slater, P. and Coffey, A. (2009) Development and
testing of the Context Assessment Index (CAI). Worldviews on Evidence Based Nursing. Vol. 6.
No. 1. pp 27-25.
Nazarko, L. (2005) How to manage residents with delirium. Nursing and Residential Care. Vol. 7.
No. 12. pp 568-570.
Department of Health (2000) Comprehensive Critical Care, A Review of Adult Critical Care
Services. London: Stationary Office.
Department of Health (2001) Building a Safer NHS for patients: Implementing an Organisation
with a Memory. London: Stationary Office.
Department of Health (2002) The Nursing Contribution to the Provision of Comprehensive Critical
Care for Adults: A Strategic Programme of Action. London: Stationary Office.
Department of Health (2008) High Quality Care for All: NHS Next Stage Review Final Report.
London: Stationary Office.
Farina, E., Pomati, S., Mariani, C. (1999) Observations on dementias with possibly revesible
symptoms. Aging. Vol. 11. No. 5. pp 323-328.
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Hersey, P. and Blanchard, K.H. (1996) Management of Organisational Behaviour: Utilising
Human Resources (7th edition). London: Prentice Hall.
McQuillan, P.et al (1998) Confidential Inquiry into the Quality of Care before Admission to
Intensive Care. British Medical Journal, 316 97148) PP 1853-1858
National Patient Safety Agency (2007) Safer Care for the Acutely Ill Patient: Learning
From Serious Incidents: 5th
Report from the Patient Safety Observatory. Accessed from:
www.npsa.nhs.uk
National Institute for Health and Clinical Excellence (2007) Acutely
Ill Patients in Hospital. Recognition Of and Response to Acute Illness in Adults in
Hospital. Guideline 50. Accessed from: www.nice.org.uk
National Institute for Health and Clinical Excellence (2010) Delirium: Diagnosis, Prevention and
Management. Guideline 103. Accessed from: www.nice.org.uk
Rycroft-Malone, J., Kitson, A., Harvey, G., McCormack, B., Seers, K., Titchen, A. and Estabrooks,
C. (2002) Ingredients for change: revisiting a conceptual framework. Quality in Health Care. Vol.
11. pp 174-180.
Thompson, C., Dowding, D. (2000) Decision Making and Judgment in Nursing: An Introduction
Clinical Decision Making and Judgment in Nursing. London: Churchill Livingstone.
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Critical to Care
Delirium (sometimes called ‘acute confusional state’) is a clinical syndrome characterized by disturbed consciousness, cognitive function or perception, which has an acute onset and fluctuating course.
NICE clinical guideline 103 (2010)
The aim of the E5 project is to provide person-centered care to recognize and prevent delirium in our patients. We aim to achieve this by good communication between patients,carers and health care professionals. This process will start from admission through to discharge and involve all members of the E5 team.
E5 Ward– Pilot
Project
Foundation of Nursing Studies
Project Team
Karen Hill Acuity Matron Chris Moffat Ward Sister Lindsay Knight Staff Nurse Clare Tull Support Sister Tracy Watt Nurse Associate Practitioner
Delirium awareness teaching sessions 17/11/10 and 18/11/10 in E5 Sisters Office
14.30-15.00
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E5 Pilot Project
Critical to Care
Hospital
No.
Date/Time
Admission
Date/Time Delirium
first
observed/reported
Action/Review
Time
MEWs/CNS
1
2
3
4
5
6
7
8
9
10
11
12
13
21
22
