Improving Delirium Screening and Management in a Hospice Inpatient Unit: Audit and Quality Improvement Cycles Using the 4AT (Alertness, Abbreviated Mental Test-4 (AMT4), Attention, Acute Change) Tool.

INTRODUCTION

Delirium is highly prevalent in palliative care settings, contributing to patient distress, poorer outcomes, and increased mortality. Although validated screening tools exist, many hospices in the UK rely on clinical judgement alone. In this study, we evaluated the use of the 4AT (Alertness, Abbreviated Mental Test-4 (AMT4), Attention, Acute Change) delirium screening tool on admission to a hospice inpatient unit (IPU) and implemented quality improvement (QI) interventions to enhance subsequent documentation and management.

METHODS

A retrospective audit of 25 admissions to the IPU at Princess Alice Hospice in London, UK, in August 2023, assessed 4AT completion rates, resultant scores, documentation of contributing factors, and clinical actions taken. The findings informed a QI project employing two Plan-Do-Study-Act (PDSA) cycles. Interventions included modifying the electronic medical record (EMR) template, embedding a delirium clinical guide, and educating clinicians. Anonymous questionnaires gathered feedback on usability and clinician confidence before and after the interventions.

RESULTS

In the audit, 88% of patients had 4AT assessments completed, with 36% scoring ≥4 (suggesting possible delirium). No explicit causes or structured action plans were recorded, despite the implication of contributing factors. Following QI interventions, staff reported that the modified EMR template had improved their documentation and was user-friendly. Clinician confidence in managing patients with high 4AT scores increased: 75% of respondents felt "very confident" post-intervention compared with 14% at baseline.

DISCUSSION: The 4AT screening tool can be effectively integrated into hospice admission workflows. Targeted EMR modifications and clinician education improved documentation and confidence, supporting the better identification and management of delirium. Limitations include small sample size, single-site design, and reliance on qualitative staff feedback.

CONCLUSIONS

Embedding a structured screening tool within EMR, supported by clinical guidance and education, enhances the assessment and management of delirium in hospices.