Nurses' Compliance with Delirium Assessment Protocol in a Tertiary Hospital: A Retrospective Study

Delirium is an acute neurocognitive disorder commonly affecting older adults. With Singapore's aging population, the early detection of delirium has become increasingly critical. The 4 'A's test (arousal, attention, abbreviated mental test, acute change) (4AT) assessment is a validated screening tool designed to detect delirium and is widely used in older adults. Despite its routine application, both compliance and timeliness with the Modified 4AT protocol have not yet been assessed in an acute tertiary care setting in Singapore. Delayed or inconsistent use may lead to late diagnosis and management. Therefore, this study aims to assess the compliance rate and timeliness of the Modified 4AT when screening for delirium among older adult inpatients in an acute tertiary hospital in Singapore.

For this retrospective study, electronic medical records of patients aged 65 and above admitted in an acute local tertiary hospital in Singapore between 1 June 2022 and 30 June 2023 were included in the analysis. Data extraction and record reviews were conducted between September 2023 and June 2025 using the hospital's electronic medical record system. This study was submitted to the institution's review board but received an exemption due to its nature as a retrospective review without patient contact (CIRB Ref: 2023/2457).

Of the 4821 admissions, 73.5% (n = 3545) received an assessment using a 4AT. Among those assessed, only 32.9% (n = 1168) underwent screening within the recommended 24 h of admission in accordance with the hospital's Nursing Operational Guidelines. The majority (n = 2377) had their 4AT assessments done after 24 h.

Preliminary findings suggest suboptimal compliance with delays in Modified 4AT assessments in the acute setting, potentially affecting patient outcomes. Strengthening adherence to timely delirium screening protocols may improve the care quality for older adults who are at risk.