Background Prevalence studies show that 15%–42% of patients admitted to specialist palliative care inpatient units have delirium. Symptoms of delirium are often subtle and easily missed, or misdiagnosed as fatigue or even depression, and so the use of a screening tool could improve early identification and management of delirium and lead to improved outcomes. Patients admitted to the hospice are often frail and tired, therefore a quick and easy-to-use method of cognitive assessment is essential.

Methods A quality improvement (QI) approach (PDSA: Plan, Do, Study, Act) was used to improve screening for delirium on admission to a hospice unit. A baseline measure was taken of the rate of performing cognitive assessment on admission. Five PDSA cycles were then undertaken which involved implementing change and then evaluating results through auditing case-notes and interviewing staff.

Results The first cycle determined staff preference between the Short CAM and the 4AT. Two further PDSA cycles embedded the 4AT (the preferred tool) into the admission process, establishing it as a usable tool in the hospice setting for up to 92% of admissions. A subsequent cycle showing poor sustainability prompted further improvements to staff education and changes to admission documentation.

Conclusions The 4AT is a usable tool in the hospice inpatient setting to assess patients’ cognitive state on admission, and can easily be incorporated into the admission process. The QI approach highlighted the need to link staff awareness of their use of the screening tool with perceived improvements in the treatment of delirium, which prompted the creation and implementation of a delirium checklist in the unit. Some lack of sustainability of the initial improvement was addressed by staff education and changes to the admission paperwork to ensure compliance with the use of the 4AT and sustained improvement in screening for cognitive impairment on admission.