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      A quality improvement approach to cognitive assessment on hospice admission: could we use the 4AT or Short CAM?

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          Abstract

          Background Prevalence studies show that 13%–42% of patients admitted to specialist palliative care inpatient units have delirium. Symptoms of delirium are often subtle and easily missed, or misdiagnosed as fatigue or depression, and so the use of a screening tool could improve early identification and management of delirium and lead to improved outcomes. Patients admitted to hospices are often frail and tired, therefore a quick and easy-to-use method of cognitive assessment is essential.

          Methods A quality improvement (QI) approach (PDSA: Plan, Do, Study, Act) was used to improve screening for delirium on admission to a hospice unit. A baseline measure was taken of the rate of performance of cognitive assessment on admission. Five PDSA cycles were then undertaken which involved implementing change and then evaluating results through auditing case notes and interviewing staff.

          Results The first cycle determined staff preference between two cognitive assessment methods: the Short Confusion Assessment Method and the four ‘A’s Test (4AT). Two further PDSA cycles embedded the 4AT (the preferred tool) into the admission process, establishing it as a usable tool in the hospice setting for up to 92% of admissions. A subsequent cycle showing poor sustainability prompted staff education and changes to admission documentation, resulting in an increase in cognitive assessment being performed, from 50% to 76%.

          Conclusion The 4AT is a usable tool in the hospice inpatient setting to assess patients’ cognitive state on admission and can easily be incorporated into the admission process. The QI approach highlighted the need to link staff awareness of their use of the screening tool with perceived improvements in the treatment of delirium, which prompted the creation and implementation of a ‘Delirium Checklist’. Some initial lack of sustainability was addressed by staff education and changes to the admission paperwork to ensure compliance with the use of the 4AT and sustained improvement in screening for cognitive impairment.

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          Validation of the confusion assessment method in the palliative care setting.

          The Confusion Assessment Method (CAM) is widely used in the palliative care setting despite the fact that its performance in this population has not been validated. The aim of the study was to determine the sensitivity and specificity of the CAM when used by Non-Consultant Hospital Doctors (NCHDs) working in a specialist palliative care unit. A pilot phase was performed in which NCHDs received a 1-hour training session based on the original CAM training manual. 32 patients underwent 33 assessments in the pilot phase but the sensitivity of the CAM was only 0.5 (0.22-0.78) and specificity was 1.0 (0.81-1.0). An 'enhanced' training programme was devised that took place over two 1-hour sessions and involved case-based learning focused on the areas where the NCHDs were experiencing difficulty. 52 patients underwent 54 assessments in the main phase of the study and the performance of the CAM improved significantly. Sensitivity was 0.88 (0.62-0.98) and specificity was 1.0 (0.88-1.0). The results suggest that the CAM is a valid screening tool for delirium in the palliative care setting but its performance is dependent on the skill of the operator. NCHDs require a certain standard of training before becoming proficient in its use.
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            Oxford Textbook of Palliative Medicine

            This new edition of the Oxford Textbook of Palliative Medicine has been thoroughly updated to offer a truly global perspective in this field, and new sections include information on assessment tools, care of patients with cancer, and the management of issues in the very young and the very old. It covers all the new and emerging topics, and the multi-disciplinary nature of palliative care is emphasized throughout, covering areas from ethical and communication issues, the treatment of symptoms, and the management of pain.
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              Delirium in advanced disease.

              Delirium in advanced disease, while common, is often not recognised or poorly treated. The aim of management of delirium is to assess and treat reversible causes in combination with environmental, psychological and pharmacological intervention to control symptoms. Delirium presents significant distress and impedes communication between patients and their families at the end of life. A structured approach to recognise, assess and manage delirium is essential for all clinicians caring for patients with terminal illness.
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                Author and article information

                Journal
                BMJ Open Qual
                BMJ Open Qual
                bmjqir
                bmjoq
                BMJ Open Quality
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                2399-6641
                2017
                31 August 2017
                : 6
                : 2
                : e000153
                Affiliations
                [1] departmentMarie Curie Hospice , Marie Curie , Edinburgh, UK
                Author notes
                [Correspondence to ] Dr Lucy Baird; lucybaird@ 123456nhs.net , bairdlucy@ 123456gmail.com
                Author information
                http://orcid.org/0000-0002-0516-419X
                Article
                bmjoq-2017-000153
                10.1136/bmjoq-2017-000153
                5609350
                4d94af5e-e559-4404-98d4-86aebcd32511
                © Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

                This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

                History
                : 25 June 2017
                : 30 July 2017
                Categories
                Quality Improvement Report
                1506
                Custom metadata
                unlocked

                continuous quality improvement,healthcare quality improvement,pdsa,quality improvement

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