# Implementing Standardised Delirium Screening Using the Four A's Test (4AT) in the Emergency Department: A Quality Improvement Project

## TL;DR

This study aimed to improve delirium screening in elderly emergency department patients using the 4AT test, but found only modest success despite training and reminders.

## Contribution

The study evaluates the effectiveness of implementing the 4AT delirium screening tool in an emergency department setting through quality improvement interventions.

## Key findings

- Formal teaching increased 4AT usage to 12%, but the 80% target was not met.
- Poster prompts had a limited effect, with only 8% 4AT usage recorded.
- Barriers included rotational training and challenging working conditions.

## Abstract

Introduction: Elderly patients are at risk of developing an acute, temporary change in cognition referred to as delirium. Those identified as at risk should be screened promptly when presenting to the emergency department to ensure early recognition and reversal of the underlying cause to improve outcomes. Our quality improvement project (QIP) aims to introduce standardised delirium screening into the emergency department with a target of 80% adherence.

Materials and methods: We conducted a QIP at Southend University Hospital emergency department in England from June 15, 2023 until November 7, 2023. We planned to implement the four A’s test (4AT) as the recognised standardised scoring system for delirium screening in those 65 years of age or older. The interventions included a preparatory survey, formal teaching and poster prompts. We performed three cycles of data collection with 50 patients in each set of data. Our target was 80% use of the 4AT.

Results: This QIP demonstrates a modest improvement in the use of a 4AT as the standardised delirium screening in those 65 years of age or older; however, work is still required. The first cycle of 50 patients revealed that 0 (0%) patients had documented use of 4AT for screening. Our second cycle of 50 patients performed after formal teaching to emergency doctors revealed that six (12%) patients had a documented 4AT. The third cycle performed after poster prompts had four (8%) patients having documented 4AT screening. Whilst there is improvement from baseline levels, the initial uptake in the use of 4AT was not sustained.

Conclusion: An improvement in 4AT usage was demonstrated compared to baseline with the most effective intervention being formal teaching; however, the target of 80% was not met. There are notable barriers to the implementation including rotational training and challenging working conditions. This highlights the need for robust quality improvement and systemic level change with consideration given to to implementation of 4AT during nurse triage, perhaps utilising formal teaching.