Delirium and older people: what are the constraints to best practice in acute care?

An Australian research team conducted a six-month acute care pilot study in a medical ward of a large hospital in New South Wales. Aim.  To explore ways health practitioners might redesign their practice to include prevention, early detection and management of delirium in older people based on the best current practice. Method and design.  Participatory action research (PAR) was selected as the best approach for involving ward staff to make sustainable clinical practice decisions. The PAR group comprised research academics and eight clinicians from the ward. Thirteen PAR sessions were held over 5 months. Clinicians described care of patients with delirium. Stories were analysed to identify constraints to best practice. Following PAR group debate about concerns and issues, there were actions toward improved practice taken by clinicians. Relevance to clinical practice.  The following constraints to best practice were identified: delayed transfer of patients from the Emergency Department; routine ward activities were not conducive to provision of rest and sleep; assisting with the patient's orientation was not possible as relatives were not able to accompany and/or stay with the older patient. Underreporting of delirium and attributing confusion to dementia was viewed as an education deficit across disciplines. A wide range of assessment skills was identified as prerequisites for working in this acute care ward, with older people and delirium. Clinicians perceived that management driven by length of a patient's stay was incongruent with best practice delirium care which required more time for older patients to recover from delirium. Two significant actions towards practice improvement were undertaken by this PAR group: (i) development of a draft delirium alert prevention protocol and (ii) a separate section of the ward became a dedicated space for the care of patients with delirium. A larger study is being planned across a variety of settings.