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

## TL;DR

This study found that nurses in a Singapore hospital often delayed or skipped a delirium screening test for elderly patients, which could lead to late diagnosis and worse outcomes.

## Contribution

The study is the first to assess compliance and timeliness of the Modified 4AT protocol in an acute tertiary care setting in Singapore.

## Key findings

- Only 32.9% of patients received the 4AT screening within the recommended 24 hours of admission.
- The majority of patients (73.5%) were assessed for delirium, but most assessments occurred after the recommended timeframe.
- Suboptimal compliance and delayed screening may affect patient outcomes for older adults at risk of delirium.

## Abstract

What are the main findings?
Suboptimal compliance to 4AT screening assessment.Delayed screening of delirium among patients.

Suboptimal compliance to 4AT screening assessment.

Delayed screening of delirium among patients.

What are the implications of the main findings?
Further quality improvement and research study is needed to improve nurses adherence to assessment protocol.Hospitals should focus on improving timeliness of performing 4AT.

Further quality improvement and research study is needed to improve nurses adherence to assessment protocol.

Hospitals should focus on improving timeliness of performing 4AT.

Background/Aim: 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. Methods: 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). Results: 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. Conclusions: 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.