Project Summary
Barossa Village Inc in partnership with The University of Wollongong, Tanunda Lutheran Home Inc, Wheatfields Inc, Kalyra Belair Residential Aged Care, Alstonville Clinic and Australian Delirium Association, and the University of New South Wales has been awarded an ARIIA grant for their project ‘“They weren't like this yesterday”: Ensuring delirium is recognised as a medical emergency in residential aged care facilities’.
Delirium is a medical emergency [2]. Despite this, delirium is commonly missed because it is misdiagnosed as dementia or simply expected in older people. This project will implement and evaluate an evidence-based intervention to improve delirium care in residential aged care. Four residential aged care facilities in inner regional South Australia will work with UOW to deliver an education intervention to improve knowledge, competence, and confidence among nursing teams about prevention and recognition of delirium.
This project addresses a noticeable gap in delirium care evidence that is overwhelmingly focused in hospitals. The team has established track records in delivering innovative aged care solutions. The knowledge translation strategies are tried and tested in hospitals in NSW and internationally in Taiwan. Capacity building is integral to this project with nursing teams leading the intervention. This approach will empower nursing teams to improve the health of older people and gain greater job satisfaction. At no previous time, has this approach been so important with the regional aged care workforce in crisis. At the conclusion of the project, a toolkit will be made available to ensure others can replicate this project and improve delirium care for older people in residential aged care.
Project Outcomes
Background and Aims
This project aimed to demonstrate that through the screening of residents who live in residential care for their risk of delirium there could be a reduction in the incidence of and the severity of delirium. The key aspects of this project were in the provision of training and tools to nursing staff further developing their understanding of delirium and its impact. There was also a tool which was developed at Barossa Village, the Delirium risk assessment tool (D-RAS) which was developed to give junior clinicians a framework to understand delirium and the urgency in the proactive management of delirium for those who are most susceptible.
Key Aims
- Recognise delirium as a medical emergency in residential aged care facilities (RACFs).
A Key feature of the training was raising the awareness of the impacts of delirium and through timely intervention we would be able to improve the quality of life for people living in residential aged care. By giving participants, the language, the skills and an understanding of the urgency of the issues supports nursing staff to be better advocates for residents. This was a key aim of the project and something that we have anecdotally seen improvement at all sites.
- Implement and evaluate an evidence-based education intervention to improve delirium care.
The evidence which was used to develop and adapt training came from the ADHER projects. The support of Dr Alera Bowden who was the chief investigator on a similar project in NSW health certainly assisted in the development and adaptation of resources to the residential aged care environment.
- Develop a delirium care education toolkit and a knowledge translation program for RACFs.
The session that was held in Nuriootpa in February 2024 was instrumental in beginning the knowledge translation journey. The general understanding of the impact of delirium was low and considered an unfortunate consequence of getting older and part of the development of dementia. However, by working through the NSW tool kit and sharing vignettes about residents who were living who had developed delirium. Quickly opportunities to arrest and support a person with delirium were identified and steps which could minimise the impact of delirium identified.
- Improve health outcomes for older people and workforce capability in aged care.
From the project beginning there was an understanding that delirium was a factor in reducing the quality of life for our residents. Before the project began at Barossa Village the health metric was the most significant factor in Impacting the quality of life of residents. The rise of infections and the increase in pain were linked to the this. Through the provision of training, it was believed and demonstrated that the early identification and management of delirium would be beneficial to the improving the health outcomes for people living in residential aged care. The focus on managing residents who had delirium had been the residents who exhibited behaviours which impacted on others, or a hyperactive delirium often coupled with dementia. However, it was the residents who were suffering from hypoactive delirium were often overlooked and had worse outcome than the hyperactive delirium residents. This insight further supported the sites who participated to implement the training and the assessment tools. The sites were also surprised by the people who were at risk and not considered a risk due to improved understanding of hypoactive delirium.
What We Did
- Delivered a multi-component education intervention across four RACFs in South Australia.
The training which was provided in its entirety to 122 staff members. There were 29 Registered nurses, 35 Enrolled nurses, and 58 care staff trained. The training consisted of a workbook, training session, a reflection and an OSCE.
- Used interactive learning including OSCEs (Objective Structured Clinical Examinations), online modules, and reflective practice.
The training module was an adaptation of the work which was done in the NSW health delirium project. The development of the OSCEs and the training of the people to participate in the OSCE and assessed the OSCE was specifically designed by the investigators for this project. We found that the OSCE was a great way of learning and the staff who responded to the post workshop survey found this the most confronting and the most beneficial type of learning.
- Developed and trialled the Delirium Risk Assessment Screening (D-RAS) tool.
The D-RAS training was developed and sent to sites to administer. What we found was unless the D-RAS was embedded in the electronic assessment tools it was not done reliably. It was viewed by staff as a valuable tool but as it didn’t directly impact the care plan formulation without the link it was not reliably completed. In instances where it was completed it was completed for people who had an obvious risk of Delirium and was living with dementia. It was determined by participants that the use of the 4AT as a delirium screening tool when there was a noted change was considered of higher importance and better understood by medical staff. Undeterred the D-RAS will continue to be administered at Barossa Village.
- Engaged stakeholders through co-design workshops, recruited clinical champions, and trained role players to simulate delirium scenarios.
Through the whole program there was support from the recruited champions, particularly at two sites. There were some challenges in getting the trained role players to each site. This was overcome by training staff to do this at the sites which was effective. The co-design of the scenarios happened with community members and residents and their insights enabled this translation.
- Conducted evaluation activities including surveys, clinical audits, and observational studies.
As part of the delirium project, a baseline survey was conducted to assess staff knowledge of delirium, followed by post-training surveys administered throughout the duration of the initiative. Significant discussion was dedicated to identifying meaningful outcome measures for residents within the facility.
The most valuable metric identified was the number of residents who received a delirium assessment before and after the intervention. At Barossa Village, this was evaluated through a retrospective review of case files. In the three month period corresponding to the previous year (prior to the intervention), six 4AT assessments were completed. In contrast, during the three months following the intervention, 22 assessments were conducted.
This marked increase in assessments indicates that heightened awareness led to a more proactive approach to identifying and managing delirium among residents.
Outcomes
- Improved knowledge, competence, and confidence among nursing staff in delirium care.
There was a clear increase in the knowledge and therefore the competence and confidence of staff in the management of delirium in the facilities who participated in the project.
- Enhanced early detection and management of delirium.
With the increased awareness of delirium there were instances reported where there were advanced care plans put in place. These care plans formulated with the GPs incorporated anticipatory prescribing to assist in the management of residents with clear guidelines on when these interventions were applied. The best example of this was a resident with Airways disease who was particularly prone to chest infections would have prednisolone when there was the first indications of an infections. This could be started at any time and did clearly prevent this resident developing further complications from his chest infection which included delirium.
- Reduced adverse events such as falls and hospital admissions.
While the project did not demonstrate a clear reduction in hospital admissions or falls both of which remained consistent throughout the intervention period. We did observe a notable decrease in the duration of antibiotic use and supportive care required by residents.
This suggests a potential improvement in clinical outcomes and may have positively influenced residents' quality of life. However, as quality of life was not explicitly measured in relation to this change, any connection remains speculative and can only be considered a possible causal relationship.
- Strengthened policy and practice around delirium care in participating RACFs.
Each of the sites that participated in the project incorporated delirium management into their policy framework acknowledging that regular training needs to occur on this subject, and it is a medical emergency.
- Built capacity among clinical practitioners to lead future quality improvement initiatives.
Anecdotally of the four initial workplace champions which were appointed by each site, two have expressed interest in further study and have taken more clinical leadership in the organisations that they are from.
Impact on Aged Care and Workforce
- Empowers aged care staff to proactively manage medical emergencies like delirium.
By elevating the management of delirium to the status of medical emergency has improved responsiveness of staff to these changes. As with other medical emergencies staff will contact the medical officer regarding management earlier and with a clearer picture of the requirements for care.
- Demonstrates a scalable model for implementing evidence-based care in aged care settings.
Using Blooms taxonomy framework to develop and implement training to staff in the aged care environment seems to be effective in the training and changing of staff behaviour. The use of the OSCE is time consuming and if administered effectively valuable in supporting information retention.
Resources Developed
- Delirium Care Flip Chart
- Delirium Care Booklets
- Interactive Education Modules for RNs and care workers
- Video Vignettes simulating patient journeys and screening tools
- Clinical Observation Evaluation Tool
- Webpage Toolkit with access to all resources Delirium Care | Aged Dementia Health Education & Research
Next Steps
- Continue dissemination through publications, conferences, and seminars.
This project was presented at the Dementia in aged care conference in Melbourne 17th of June 2025 as part of a presentation on innovation and excellence in aged care.
Journal article prepared for publication.
Key contact for further information
Matt Kowald, General Manager, Barossa Village