Retrospective process evaluation of the implementation of the Pilgrims Hospices delirium toolkit in three inpatient settings in east Kent, England.
Mrs Charlotte Brigden, Masters in Sociological Research - Research Facilitator & Academic Researcher, Pilgrims Hospices in east Kent.
Supported on the project by: Amanda Timms, Advanced Nurse Practitioner Justine Robinson, Therapy and Wellbeing Services manager/ Lead Occupational Therapist
- Osborne G, Timms A, Bembridge H, et al. O-17 Our patient is not muddled, they have delirium: improving recognition and care in hospice settings BMJ Supportive & Palliative Care 2021;11:A7.
- Hashem F, Brigden C, Wilson P, Butler C. Understanding what works, why and in what circumstances in hospice at home services for end-of-life care: Applying a realist logic of analysis to a systematically searched literature review. Palliative Medicine. 2020;34(1):16-31.
- Brigden C, Thorns A, Hills W, et al. Evaluation of a nurse directed beds model of care in a stand-alone hospice inpatient unit (IPU) BMJ Supportive & Palliative Care 2018;8:360.
What are the effects of a delirium toolkit on patient care in a palliative care in-patient unit setting?
What is the specific problem that you intend to explore?
Most patients want to retain clear cognition at the end of life (Bush et al 2017, 2020, Hosker et al 2016). Delirium, when cognition becomes impaired, is a common condition in palliative care and can be distressing for patients/families and challenging for staff. It affects between 13-42% of hospice inpatients (Hosie et al 2013, Watt et al 2019) and 80% of patients with cancer in last 2 weeks of life.
Despite this commonality delirium is often under-recognised and poorly managed. A third - half of all delirium cases are potentially reversible. Pharmacological management in this field is contentious (Agar 2020], Hosker et al 2016), highlighting the importance of non-pharmacological approaches (NICE 2019). Due to limited understanding of delirium among palliative care nurses and other clinicians the focus has been on symptom management, rather than prevention, early identification and modification of possible causes (Featherstone et al 2021).
What method(s) will you choose in order to solve this problem?
Pilgrims Hospices has already set up a multidisciplinary Delirium Working Group (2019) in response to their own local delirium audit, showing areas requiring improvement within delirium care. The group developed a Delirium Toolkit, consisting of a ‘Step-by-Step’ checklist (accessible in electronic patient records); patient information leaflet, non-pharmacological checklist ‘I want great care’ form, the 4AT tool (a validated screening tool for delirium (4AT), fuller hospice-specific guideline and NICE Quick Guide for Care Homes.
The toolkit was implemented through an Awareness Week and enhanced Education Program and new induction/refresher e-learning module for staff. Delirium Champions were recruited and ‘Delirium’ is now a component of the ‘Transfer of Care Form’. An assessment flowchart was also developed to support staff with the process to follow when using the toolkit.
We wish to apply for this award to evaluate how well the implementation of toolkit has enabled improvement in the recognition and management of patients with delirium in hospice inpatient units at Pilgrims Hospices, to improve practice and patient care in relation to delirium.
The objectives will be to assess whether:
1. The implementation of a delirium toolkit enabled healthcare staff on hospice inpatient units to be able to (or be more confident to) identify patients with delirium.
2. The implementation of a delirium toolkit enabled healthcare staff on hospice inpatient units to be more confident/able to manage their care.
3. The implementation of the delirium toolkit improved care outcomes for the patients e.g. modification of potential causes, increase in non pharmacological interventions, decrease in drug use. The Hospice Research Facilitation and Governance Forum will provide project governance and ethical approval and oversight.