Delirium Risk Assessment Sticker

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					                                        Tool and Resource Evaluation Template
                     Adapted by NARI from an evaluation template created by Melbourne Health.

Some questions may not be applicable to every tool and resource.

Name and purpose     Name of the resource: The Delirium Risk Assessment Sticker
                     Author(s) of the resource:
                     Ms Julia Poole, Ms Brandi Cole, Dr Sue Ogle, Dr Terry Finnegan
                     Northern Sydney Central Coast Health Service
                     Please state why the resource was developed and what gap it proposes to fill:
                     The resource was developed as part of a Clinical Redesign Project, conducted between October
                     and December 2007. The aim of which was to provide best practice prevention and management
                     of delirium and dementia by providing staff with education and tools to assist in the recognition of
                     these conditions; and by doing so reduce restraint use and adverse events.
                     The Delirium Risk Assessment (DRA) Sticker is based on information contained in Clinical practice
                                                                                 1
                     guidelines for the management of delirium in older people . It provides a useful prompt for clinical
                     staff in terms of risk factors, prevention, diagnosis and management of delirium.
                     Evaluation of the DRA sticker, in the abovementioned Clinical Redesign Project, showed that it
                     improved staff awareness of delirium and delirium risk factors and increased delirium recognition.

Target audience      Please check all that apply:
(the tool is to be
used by)                Health service users         Carers
                        Medical staff                Nursing staff           Any member of an interdisciplinary team
                        Medical specialist, please specify:
                        Specific allied health staff, please specify:
                        Other, please specify:

Target               Is the resource targeted for a specific setting? Please check all that apply:
population/setting
(to be used on/in)     Emergency Department          Inpatient acute      Inpatient subacute       Ambulatory
                       Other, please specify:
                     For which particular health service users would you use this resource (e.g. a person with
                     suspected cognitive impairment)?
                     Persons aged 70 years and over and those with existing cognitive impairment are at high risk for
                     the development of delirium, but many other risk factors exist.

Structure of tool      Website              Education package             Video
                       Pamphlet              Assessment tool              Screening tool
                       Methodology          Resource guide                Awareness raising resource (posters etc.)
                       Other, please specify:
                     Please state the size of the resource (e.g. number of pages, minutes to read):
                     The Delirium Risk Assessment (DRA) Sticker is a half-page table comprising information on risk
                     factors for the development of delirium, recommended investigations if delirium is suspected and
                     strategies that can be useful in both the prevention of delirium and management of symptoms.
                     The DRA Sticker can be printed two-to-a-page, using full-page A4 label sheets. These are then
                     peeled off and stuck on to progress notes in the patients’ medical record.

Availability and     Is the resource readily available?       Yes    No    Unknown        Not applicable
cost of tool
                     Is there a cost for the resource?        Yes    No     Unknown       Not applicable
                     Please state how to get the resource:
                     A copy of the DRA sticker is provided below:
                     Delirium Risk Screen Sticker


                     For further information, contact
                     Julia Poole, Clinical Nurse Consultant, Aged Care
                     Dept of Aged Care & Rehabilitation Medicine,
                      Building 10, Royal North Shore Hospital
                      ST LEONARDS NSW AUSTRALIA, 2065
                      jpoole@nsccahs.health.nsw.gov.au

Applicability to      Is the resource suitable for use in rural health services (e.g. the necessary staff are usually
rural settings and    available in rural settings)?    Yes     No     Unknown      Not applicable
culturally and        Is the resource available in different languages?
linguistically
diverse                  Yes     No      Unknown        Not applicable
populations
                      Is the content appropriate for different cultural groups?
                         Yes     No      Unknown        Not applicable

Person-centred        Does the resource adhere to/promote person-centred health care?
principles              Yes      No     Unknown        Not applicable

Training              Is additional training necessary to use the resource?
requirements            Yes     No     Unknown        Not applicable
                      If applicable, please state how extensive any training is, and what resources are required:
                      Use of the DRA sticker requires familiarity with the resources from which it was developed, e.g.
                      Clinical practice guidelines for the management of delirium in older people1 and the Confusion
                                                    2
                      Assessment Method (CAM) . Reviews have been included in the toolkit for both resources.

Administration        How long does the resource take to use?           0-5 mins     5-15 mins      15-25mins       25mins +
details               The DRA sticker may be completed over time. On admission, the risk factors/risk score section
                      may be all that is completed. However a change in behaviour, function and/or cognition would see
                      the investigations section completed.
                      Can the resource be used as a standalone, or must it be used in conjunction with other
                      tools, resources, and procedures?

                         Standalone
                         Must be used with other resources, please specify: Clinical practice guidelines for the
                                                            1     2                                              3
                      management of delirium in older people , CAM , validated cognitive assessments such as AMT
                                4
                      and MMSE .
                         Can be used with other tools, please specify:

Data collection and   Are additional resources required to collect and analyse data from the resource?
analysis
                        Yes     No     Unknown        Not applicable
                      If applicable, please state any special resources required (e.g. computer software):
                      Additional resources are required to collect the data necessary to complete the Delirium Risk
                      Assessment. See administration details (above)

Sensitivity and       Sensitivity is the proportion of people that will be correctly identified by the tool.
specificity           Specificity is the probability that an individual who does not have the condition being tested
                      for will be correctly identified as negative.

                      Has the sensitivity and specificity of the resource been reported?
                        Yes     No     Unknown       Not applicable

                      If applicable, please state what has been reported:
                      While sensitivity of the DRA sticker itself has not been reported, the tool is based on clinical
                      guidelines and the use of instruments that are well validated.

Face Validity         Does the resource appear to meet the intended purpose?
                        Yes     No    Unknown     Not applicable
Reliability           Reliability is the extent to which the tool’s measurements remain consistent over repeated
                      tests of the same subject under identical conditions. Inter-rater reliability measures
                      whether independent assessors will give similar scores under similar conditions.

                      Has the reliability of the resource been reported?
                        Yes     No      Unknown       Not applicable

                      If applicable, please state what has been reported:
                      While reliability of the DRA sticker itself has not been reported, the tool is based on clinical
                      guidelines and the use of instruments that are well validated.
Strengths         What are the strengths of the resource? Is the resource easy to understand and use? Are
                  instructions provided on how to use the resource? Is the resource visually well presented
                  (images, colour, font type/ size)? Does the resource use older friendly terminology (where
                  relevant), avoiding jargon?
                  Please state any other known strengths, using dot points:
                       •   Based on Clinical practice guidelines for the management of delirium in older people1
                       •   Provides useful prompts for clinical staff to consider delirium risk factors and preventative
                           strategies
                       •   Lists the components of diagnostic investigation if delirium is suspected
Limitations       What are the limitations of the tool/resource? Is the tool/resource difficult to understand
                  and use? Are instructions provided on how to use the tool/resource? Is the tool/resource
                  poorly presented (images, colour, font type/ size)? Does the tool/resource use difficult to
                  understand jargon?
                  Please state any other known limitations, using dot points:
                       •   The DRA sticker has had limited evaluation

References and    Supporting references and associated reading.
further reading
                  1.   Clinical Epidemiology and Health Service Evaluation Unit and Delirium Clinical Guidelines
                       Expert Working Group. Clinical practice guidelines for the management of delirium in older
                       people. Victorian Government Department of Human Services, on behalf of the Australian
                       Health Ministers' Advisory Council (AHMAC), Melbourne. 2006.
                       http://www.health.vic.gov.au/acute-agedcare/ (accessed 18 February 2008)
                  2.   Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the
                       confusion assessment method. A new method for detection of delirium. Annals of Internal
                       Medicine, 1990;113(12):941-8.
                  3.   Hodkinson HM. Evaluation of a mental test score for assessment of mental impairment in the
                       elderly. Age & Ageing, 1972;1(4):233-8.
                  4.   Folstein MF, Folstein SE, McHugh PR. "Mini-mental state". A practical method for grading the
                       cognitive state of patients for the clinician. Journal of Psychiatric Research, 1975;12(3):189-
                       98.
   Northern Sydney Central Coast Health Service                              Assessment to be completed on admission, pre &
                                                                             post op. and when there is a change in behaviour
 > 70 yrs Delirium Risk Screen (Modified Inouye)                             (See: Management of Confusion/Poole’s Algorithm)
                                                                                        Tick &     Precipitating factors
                         Pre morbid risk factors                                          add
                                                                                         score
                                                                                                          WARNING: these
    Visual impairment (unable to read large print on newspaper with                                       factors increase risk
    glasses)
                                                                                              1
                                                                                                          •     Mechanical restraint
    Severe illness (nurses’ opinion including mental Illness or                               1           •     Malnutrition
    depression)
   Cognitive impairment             AMTS <7/10 or MMSE < 25/30 or                                         •     3 new medications
                                                                                              2                 added in 24hrs
   past history of memory or cognitive deficit
   Dehydration (scanty, concentrated urine; fever, thirst, dry mucous                         1           •     IDC
   membranes or raised creatinine/urea)                                                                   •     Iatrogenic event
Score: 0 = low risk 1-2 = medium risk ≥3 = high risk of delirium                             Score              (procedure, infection,
                                                                                                                complication, fall etc)

                            Delirium Risk               Low                 Med                   High
If change in behaviour    CAM *       Medical             History          Physical        Medication Review             Bloods            MSU
    RECOMMENDED                                      (incl. family)
                                     review                                Exam
   INVESTIGATIONS

Delirium diagnosed                     Yes             No
Delirium Prevention And Management Protocol                      See: Australian guidelines http://www.health.vic.gov.au/acute-agedcare/
Cognition         • Establish cognitive baseline                      Vision &       •   Clean glasses
                    AMTS or MMSE                                      Hearing        •   Working hearing aid
                  • Completed Communication & Care                    Drugs          •   Pharmacy review done
                    Cues form in bed notes (Poole’s Algorithm)                       •   Use antipsychotics with caution
                  • Interpreters, language aids                                      •   Hypnotics or ETOH withdrawal schedule
                  • Delirium brochure to family & sitters                            •   Regular pain relief
Hydration,        • Review hydration                                  Sleep           • Quiet & comfort – usual settling routine
Nutrition &       • Review food / dentures                                            • Avoid unnecessary hypnotics
Elimination
                  • Avoid IDCs & constipation                                         • Offer snacks & avoid caffeine
Mobilisation      • Active, early independence –                      Consult &      • Consult Geriatrician
& Activities                                                          Monitor        • Test & review cognition often
                     Physiotherapy and Walking Program

Signatures: Med Officer:______________________ Date: ____/____/____ Nursing ______________________Date: ____/____/____
* Confusion Assessment Method (CAM) = Delirium diagnostic tool (Inouye et al. 1990 Annals of Internal Medicine. 113:941)
FEB08                                                                                                                  CATALOGUE NO:09631



   Northern Sydney Central Coast Health Service                              Assessment to be completed on admission, pre &
                                                                             post op. and when there is a change in behaviour
 > 70 yrs Delirium Risk Screen (Modified Inouye)                             (See: Management of Confusion/Poole’s Algorithm)
                                                                                        Tick &     Precipitating factors
                         Pre morbid risk factors                                          add
                                                                                         score
                                                                                                          WARNING: these
    Visual impairment (unable to read large print on newspaper with                                       factors increase risk
    glasses)
                                                                                              1
                                                                                                          •     Mechanical restraint
    Severe illness (nurses’ opinion including mental Illness or                               1           •     Malnutrition
    depression)
   Cognitive impairment             AMTS <7/10 or MMSE < 25/30 or                                         •     3 new medications
                                                                                              2                 added in 24hrs
   past history of memory or cognitive deficit
   Dehydration (scanty, concentrated urine; fever, thirst, dry mucous                         1           •     IDC
   membranes or raised creatinine/urea)                                                                   •     Iatrogenic event
Score: 0 = low risk 1-2 = medium risk ≥3 = high risk of delirium                             Score              (procedure, infection,
                                                                                                                complication, fall etc)

                            Delirium Risk               Low                 Med                   High
If change in behaviour    CAM *       Medical             History          Physical        Medication Review             Bloods            MSU
    RECOMMENDED                                      (incl. family)
                                     review                                Exam
   INVESTIGATIONS

Delirium diagnosed                     Yes             No
Delirium Prevention And Management Protocol                      See: Australian guidelines http://www.health.vic.gov.au/acute-agedcare/
Cognition         • Establish cognitive baseline                      Vision &       •   Clean glasses
                    AMTS or MMSE                                      Hearing        •   Working hearing aid
                  • Completed Communication & Care                    Drugs          •   Pharmacy review done
                    Cues form in bed notes (Poole’s Algorithm)                       •   Use antipsychotics with caution
                  • Interpreters, language aids                                      •   Hypnotics or ETOH withdrawal schedule
                  • Delirium brochure to family & sitters                            •   Regular pain relief
Hydration,        • Review hydration                                  Sleep           • Quiet & comfort – usual settling routine
Nutrition &       • Review food / dentures                                            • Avoid unnecessary hypnotics
Elimination
                  • Avoid IDCs & constipation                                         • Offer snacks & avoid caffeine
Mobilisation      • Active, early independence –                      Consult &      • Consult Geriatrician
& Activities                                                          Monitor        • Test & review cognition often
                     Physiotherapy and Walking Program

Signatures: Med Officer:______________________ Date: ____/____/____ Nursing ______________________Date: ____/____/____
* Confusion Assessment Method (CAM) = Delirium diagnostic tool (Inouye et al. 1990 Annals of Internal Medicine. 113:941)
FEB08                                                                                                                  CATALOGUE NO:09631