Using Simulation Education to Improve Delirium Care

Innovative Delirium Care Education using Objective Structured Clinical Examinations (OSCEs) to Improve the Clinical Skills and Competence of Clinicians

The session will cover 15 topics using a quiz type question and answer format with the participants, including

  • risk factors causing delirium;
  • causes of delirium;
  • recognising delirium
  • management approaches for delirium; and
  • lay person’s view of delirium and what it feels like to have a delirium.


Part of this session includes form fields where you can type in your notes to the question/task at hand. These will not be saved or submitted anywhere. You can use the "Print my notes" button to show these notes in a printable view that you can print off for your own records. Alternately you may choose to use a notepad and write down your responses by hand.


 

Reviewing the patient journey for individuals experiencing a delirium

These four videos cover the following aspects of delirium care (Figure 2):

  • admission via the emergency department and a hyperactive delirium;
  • recognising delirium through the use of a screening tool and talking in-depth with a family carer;
  • a hypoactive delirium episode; and
  • discharge planning with the older person and a family member.

Vignettes
Figure 2: Online Learning Activity 1: 'The Patient Journey: Delirium care in acute care settings'
(Adapted from University of Wollongong, 2011)

Viewing these four videos will take 15 minutes.

Participants will be invited to take notes about what they learned watching the filmed vignettes demonstrating best practice delirium care.


Screening for delirium and caring for an individual experiencing a delirium

The three filmed vignettes cover the following aspects of delirium care (Figure 3):
  • using the Confusion Assessment Method (CAM) to screen for delirium;
  • managing a hypoactive delirium; and
  • managing a hyperactive delirium.

Learn about Delirium
Figure 3: Online Learning Activity 2: 'Learn about Delirium'
(Adapted from Queensland University of Technology, 2014)

Participants will be invited to take notes about what they learned watching the filmed vignettes demonstrating best practice delirium care.


Reflective activity: Preparation learning activities

The purpose of completing this preparation activity is for you to have an opportunity to think about your clinical strengths and identify specific areas where you can gain further development in the topics areas focused on in the OSCE.

  1. Deteriorating health conditions: Appropriate responses for older people:
    1. Recognising delirium in older people; and
    2. Escalating and reporting deteriorating health conditions in older people.

Preparation Activity 1:
(i) Recognising and (ii) Escalating and reporting delirium in older people

Time This activity will take approximately thirty minutes to complete.

The causes of delirium for an older person living independently in the community or with the support of residential accommodation services will, inevitably, vary. What we know in the hospital setting is that patients who are acutely ill have an increased risk of experiencing deterioration in their condition and the signs are often sudden and dramatic.

In contrast, older people who experience delirium may only display subtle signs, which can be further disguised by pre-existing co-morbidities. Clinicians working with older people need to develop advanced clinical skills which include understanding delirium, to ensure they can recognise common signs of delirium and initiate appropriate responses.

Think
To start with, we invite you to recall from your experience, an older person who you worked with who experienced delirium. This may be someone you have recently looked after or someone who is a patient on the ward at the moment.

Give this person a pseudonym so you can write about him/ her in the first person.

List the signs, symptoms, clinical observations and general observations which alerted you to the early stages of the delirium which this older person was experiencing.

Begin to reflect on and consider in more detail the situation are recalling from your experience.

What happened?

Describe how you knew the health condition of the older person had developed delirium. You might want to include the vital sign recording you did or something more intuitive from your general impressions about what was happening to the older person who you were working with.

What was good and bad about the situation you are recalling from your experience?

What actions do you consider had a (i) positive impact on the situation and (ii) negative impact on the situation?

What else could have been done about the situation you are recalling from your experience?

When we have time to reflect on a situation we are sometimes able to think about what we or others could have done differently to ensure a different and more positive outcome was achieved. List anything you can think of that would have helped recognise the deterioration earlier or enabled the reporting of the deterioration to be more successful.


Objective structured clinical examinations (OSCEs)

Scenario 1: Older man admitted from home

Clinician (assessee) undertaking OSCE instructions

Before each clinician undertakes an OSCE the assessor reads the following out and hands the assessee a printed copy of the patient scenario for the OSCE:

“This is your patient scenario:

‘Mr. Allan is a 70 year old man who has been in acute care hospital for the past 5 days with a diagnosis of pneumonia.

Mr Allan was admitted to your hospital yesterday morning.

Two days ago Mr Allan had his medication regime amended two, including a prescription for temazepam by a medical officer because he was unable to sleep. During the morning handover, the night staff reported that Mr Allan had not slept well. Several times during the time, Mr Allan was found in the ward away from his bed area, appeared disorientated and had to be assisted to find his way back to his bed.’ ”

Documents provided to the OSCE assessee:

  • blank standard observation chart; and
  • blank delirium screen for older adults

Blank Observation Chart
Patient Details 1: Blank observation chart
Click for full size

Blank delerium screen
Patient Details 2: Blank delirium screen for older adults
Click for full size

OSCE Assessor Documentation

OSCE Assessment Criteria

Assessment criteria Yes No Detailed assessment criteria (if Yes)
  1. Reads patients admission history, recognises and verbalises possible risk factors for delirium
   
  • Age 65yrs or older
  • Past or present cognitive impairment and/or dementia
  • Severe illness
  • Sleep deprivation
  • Change in medication
  • Dehydration
  1. Reviews progress notes/medication chart
    Talks out loud and explains that there are documented changes to:
  • Behaviour and the addition of new medication
  1. Introduces themselves to patient
   
  • Uses patients name and tells them their name
  1. Assessment of patient and the situation/ Recognition of change in patients behaviour and re-orientates him to his surroundings
    Talks out loud and explains that:
  • Patient is no longer orientated to time and place
  • Describes change in behaviour
  1. Recognition of risk factors
    Talks out loud and explains that there are documented changes to:
  • The change in medication and the addition of benzodiazepines
  • Identifies that medication should not make patient drowsy during the day
  • Recognises that benzodiazepines may increase risk of delirium
  • change in environment
  1. Nursing Actions
   
  • Checks vital signs and neurological status
  • Reassesses using AMTS – 6/10
  • Clinician refers to and uses the Confusion Assessment Method (CAM)
  1. Management
    Talks aloud explaining that:
  • Medical officer will be contacted to report the AMTS and CAM outcome
  • Communicates using ISBAR expresses concerns that patient has delirium
  1. Documentation
   
  • Accurate recording of assessment of patient on observation chart and in progress notes
Talks out loud and explains that there are documented changes to:
  • Communicates interventions to relevant staff and in shift handover
  1. Concludes the therapeutic relationship with patient
    Closes interaction with patient:
  • Ensures dignity and privacy and comfort
  • Continues to re-orientate patient.
  1. Uses appropriate verbal and non-verbal communication
     

Figure 6: OSCE Criteria: Assessing for delirium during an acute hospital stay for treatment of pneumonia

Client/ standardised patient instructions for role playing delirium care scenario

You are a 70 year old man who has been in acute care hospital for the past 5 days with a diagnosis of pneumonia. You were transferred to this hospital yesterday morning. You have had trouble sleeping. Two days ago the doctor ordered you something to help you sleep. You now feel unsettled all the time you don’t have your watch and can’t see a clock. During the night there were people who kept coming to tell you to go back to bed. Where is your wife? Why has she gone away?


Objective structured clinical examinations (OSCEs)

Scenario 2: Older woman admitted to hospital from the nursing home where she lives

Clinician (assessee) undertaking OSCE instructions

Before each clinician undertakes an OSCE the assessor reads the following out and hands the assessee a printed copy of the patient scenario for the OSCE:

“This is your patient scenario:

‘Mrs. Petersen is an 82 year old lady admitted from a residential aged care facility with decreased mobility and a decline in cognition. She has a past history of stroke, which has left her with a mild right sided weakness. She has become disorientated to time and place. She has a past history of UTI’s. She normally spends time quietly reading, she is now restless and seems agitated. On admission to the ward her Abbreviated Mental Test Score (AMTS) was 6/10.’ ”

Documents provided to the OSCE assessee:

  • completed standard observation chart; and
  • completed delirium screen for older adults.

Completed Observation Chart
Patient Details 3: Observation chart: Mrs Peterson: OSCE 2: Recognising Delirium
Click for full size

Completed delerium screen
Patient Details 4: Delirium screen for older adults
Click for full size

OSCE Assessor Documentation

OSCE Assessment Criteria

Assessment criteria Yes No Detailed assessment criteria (if Yes)
  1. Reads patients admission history, recognises and verbalises possible risk factors for delirium
   
  • Age 65yrs or older
  • Mild cognitive impairment, early stage of dementia
  • Past medical history (CVA)
  • Metabolic derangement (UTI)
  • Possible pain associated with UTI
  • Sleep deprivation
  1. Reviews progress notes/medication chart
    Talks aloud explaining that there are:
  • Documented changes to behaviour
  1. Introduces themselves to patient
   
  • Uses patients name and tells them their own name
  1. Assessment of patient and the situation/ Recognition of change in patients behaviour and re-orientates him to his surroundings
    Reads aloud explaining that:
  • Patient no longer orientated to time and place
  • May have pain due to ? UTI
  1. Recognition of risk factors
    Talks aloud explaining that:
  • Recognise patient at risk of UTI due to:
  • Past history
  • Early dementia
  • Age
  • Change of environment
  • Pain
  1. Nursing Actions
   
  • Checks vital signs and neurological status using DRAT
  • Refers to and uses the Confusion Assessment Method (CAM)
  • Re-orientates patient to time and place
  1. Management
    Talks aloud explaining that:
  • Medical officer will be contacted to report the CAM outcome
  • Communicates using ISBAR expresses concerns that patient has delirium
  1. Documentation
   
  • Accurate recording of assessment of patient on observation chart, care plan and progress notes.
  • Increase fluid intake
  1. Concludes the therapeutic relationship with patient
    Closes interaction:
  • Ensures dignity and privacy and comfort
  • Continues to re-orientate patient
  1. Uses appropriate verbal and non-verbal communication
     

Figure 9: OSCE Criteria: Assessing for delirium during an acute hospital admission for assessment of agitation

Client/standardised patient instructions for role playing delirium care scenario

You are an 82 year lady who has been admitted a week ago from an aged care facility with decreased mobility. Over the past two days it has become painful to pass urine, so you are not drinking as much as usual and you are putting of going to the toilet due to the pain. You can’t concentrate on your reading, which you love. You feel restless and agitated. You’re not sure where you are, and who are these other people in your room.



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