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The Pinch Me Pod – an MDT approach to delirium in hospital settings
This is the ‘Pinch Me Pod’, a podcast resource from the Northern Health and Social Care Trust, to help explore the topic of delirium in detail, and what the multidisciplinary team can do to recognise and manage delirium in the hospital setting.
Dr Stephen Collins, Doctor in Elderly Care Medicine, hosts this podcast series, alongside a panel of staff from across the acute hospitals in Antrim and Causeway, in Northern Ireland. Over the course of six episodes, we explore what delirium looks like for us in our own day-to-day work and the significant impact this condition has on patients, families and staff. As well as the lessons we have learned, we also discuss lots of tips on how you might be able to improve the level of care you provide to patients with delirium in your own work setting. We hope that this podcast will begin to answer some of the questions you may have and help you navigate the medical minefield that delirium can sometimes feel like.
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Pinch Me Pod Episode 4 Final
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This is the Pinch Me Pod, a podcast resource from the Northern Health and Social Care Trust to help you and your colleagues manage delirium better in the hospital setting.
Welcome back to episode four of our delirium podcast, brought to you by me, Stephen, and a whole host of my fantastic colleagues based here in the Northern Trust in Northern Ireland. All of us around this table work in either Causeway Hospital or Antrim Area Hospital, and our patients are often frail and elderly, making them at increased risk of developing delirium.
And every now and then, we can be faced with complex, prolonged cases of delirium that just won't shift. Often what this looks like to us is patients becoming agitated, aggressive, and unsettled. And this can be one of the most challenging aspects of delirium to manage as a member of healthcare staff. And that is why we have chosen to spend today's episode looking at this very topic.
What can we do to try and manage patients with complex, difficult and prolonged cases of delirium that don't resolve as quickly or as easily as we would like them to? One more thing, at this point it might be useful to reintroduce you to the people we have got in the room with us. So here are some of the voices you'll be hearing from today.
Hi, I'm Nicola Laughlin, Delirium Nurse Coordinator in Antrim Hospital. Hi, I'm Orla Matthews. I'm the Dementia Service Improvement Lead Nurse for Hospital Settings in the Northern Trust. Hello, I'm Stephen Johnston. I'm a consultant liaison psychiatrist working with the Mental Health Liaison Service.
Hi, I'm Jenny Preston. I'm a psychiatry registrar working with the Mental Health Liaison Service in Antrim area. Hi, I'm Darren Bridges. I am the MCA lead for acute hospitals in the Northern Trust. Hi, my name is Jackie Grier. I am a doctor in the care of the elderly team in Antrim Hospital. Hello, my name is Julie Magee. I'm the lead pharmacist for older people in the Northern Trust.
Hi, so let's jump right in. And Jackie, would you be able to start us off? And explain the reasons why delirium might escalate rather than resolve in some patients. Sometimes, as we all know, despite following the delirium pathway, looking for our triggers and making interventions, we can see that a patient's delirium is either not resolving or may indeed be getting worse, while they're under our care.
This can be for a number of reasons, and if this is the case, I suppose the first thing that we need to do is to go back to the start and reassess and see, have we missed something? Is there something else going on in the situation that's continuing to drive the delirium? It is possible that the treatment that we have initiated just isn't the right treatment, and I suppose an infection is a good example of that, that someone's possibly just not on the right antibiotic.
So considering what interventions we have made already, is always something that's good to do. If someone's been in hospital for a longer period of time, it's also possible that they've developed a new problem. So new issues such as constipation or dehydration might be exacerbating a delirium. And they should be considered and interventions made where possible.
Simple things such as considering has the patient recently been moved to a new bed on the ward can also lead to an increase in their confusion and disorientation. So again, just thinking what's happened in the last few days. Are there any new medications? Are there any new environmental factors that might have made things worse is all very important.
Usually in medicine we are taught that common things are common. So in the context of delirium, the majority of cases can be explained by one of the causes in our PINCH ME acronym. That is pain, infection, nutrition, constipation, hydration, medications and environmental change. But what do we do when common things don't happen don't explain the delirium. Stephen Johnson is a consultant psychiatrist and here he is to explain what steps can be taken if common things don't appear to explain the delirium.
I suppose at some point if a delirium isn't resolving then we need to start to think about uncommon things and that is where we might start to consider do we have the correct diagnosis. And so, often, as a liaison psychiatry team, we will come and we will assess and take a bit of a backstory about the patient and try to ascertain, is the point of admission, is the point where a delirium appeared actually the beginning of the story? Or is this just a little part of it and it is actually covered over a psychosis that the patient might be suffering from, uh, or indeed another mental illness.
And that's the value of a liaison psychiatry team coming to do a full assessment if things become unmanageable. There will also be other times where perhaps a delirium is only a small part of the picture and actually the individual has a cognitive impairment, perhaps like a dementia, and really the management of that is subtly different with regards to the medication side of it.
But there's lots of shared thoughts and shared approaches between delirium and dementia in terms of using clear communication, being willing to be repetitive with patients in order to reinforce information and providing reassurance.
Reassurance, a listening ear and clear communication are some of the main ingredients for beginning to manage someone with delirium. However, later in this episode we will touch on when it might be appropriate to give medication to settle agitation. But before we get to that, here's Orla Matthews, the dementia lead for the Northern Trust, to remind us that sedating medications can cause problems in and of themselves. And that is something we need to be mindful of.
There's a bit of a ‘catch 22’ situation with prolonged delirium. You can have those pharmacological interventions that can actually cause sedation, which lead to then those secondary issues, that Jackie spoke about where people are actually developing poor swallows because they're over sedated or they have developed a hospital acquired pneumonia because they're sedated and they're sleeping and they're lying flat and not up moving about, or in fact could end up with a hospital fall because of that.
So we know there's that sort of ‘catch 22’ situation that in the hospital environment that someone actually could be almost recovering from the delirium or out the other side of it, and then another event can happen.
So when it comes to managing patients at a practical level who have complex, prolonged delirium, here we've got Orla and first Nicola, the delirium lead for the Northern Trust, to help us think through how we could interact with these kind of patients.
Situations really can easily and quickly escalate. It can be quite complex and we need to be constantly looking and recognising escalating situations and take measures as early on as possible to try and reassure, to try and comfort, to distract, to de-escalate, try to understand and identify what the trigger has been and work it out.
I think the onus is on us to support the person in that situation where their behaviour is becoming challenging, you know, remembering that the patient is likely to be very distressed and some guidance around that is if somebody's becoming distressed, you know, as staff, we often crowd around the person. I think we're doing the right thing, that gathering, but that isn't helpful and at times it can give the impression that we're actually ganging up on the patient.
So it's about that standing back, that one person, directing, you know, and thinking about our personal space, you know, of the person, you know, that we're not directly in it. It's just important to be respectful, introduce yourself, shake hands, and just again, that show of empathy and concern. I can see you're frightened, are you okay?
You know, acknowledge their feelings, validate their feelings, you know, in that situation they find themselves in. Because it is frightening. And even using gestures to what it is you're trying to help the person with, offering them a drink or directing them to a quieter area or whatever it is, in terms of the situation.
You know, ask questions and listen to the person, listen to what they're telling you. Distraction can be very helpful and, you know, some examples is using familiar photos. You know, different objects as prompts can be useful and again very much that family involvement that is so, so helpful and paramount really.
Avoid disagreeing with a patient, getting into that argumentation of what it is they're saying and again too often a person is wanting to walk, they're wanting to get up, find out where they are. And allow that person to wonder if it's safe to do so, you know, because there may be purposeful behaviour behind it. So all in all, just trying to remain calm, self controlled and confident without being dismissive or overbearing.
I like that you said dismissive because one of my key points would be to not ignore distressed behaviours and look with complex prolonged delirium are going to come complex behaviours and we'll see that in how our patient displays their distress behaviours.
Dr. Francis Duffy is a consultant clinical psychologist in our Trust coined a phrase and it's a fantastic mantra, is that behaviour of any kind is a form of communication and it's often driven by a need. So, when we're thinking of complex behaviours, if we actually look at it from, this person is trying to tell me something, they're trying to tell me that there's an unmet need, and we need to try and get to the bottom of that, then we can respond to those complex behaviours that are associated with delirium much, much more accurately and much more therapeutically.
One thing that many of us might hear from patients with delirium on our wards is them asking for relatives who are no longer alive. Like a patient in their 80s or 90s asking for their mum or dad or grandparents. What might be causing these patients to ask for these family members? Here Orla helps walk us through what might be behind that.
As healthcare professionals, we are driven by being able to help people. And so whenever a patient is asking for something that we can't give them, we don't know how to respond and we usually ignore and walk away. And a perfect example of that when someone has a cognitive impairment like a delirium is when they're asking for a loved one who's deceased.
You know, whether it's asking for a spouse and we know they're deceased, or it's a ninety seven year old woman who's asking for her mummy. And if we flip that around to that mantra, behaviour of any kind is a form of communication that's often driven by a need, what is a person saying when they're saying I need my mummy?
Well, why do we look for a mum? And it's often in those moments of when we are frightened and terrified or sore. So actually when a person is asking for a loved one that is deceased, what the unmet need is, is reassurance. So if we can teach our health care professionals, our health care assistants, our doctors or nurses, that when someone says, do you know where my mummy is, that you don't just walk on and ignore it, but actually you recognise it, this is someone saying, I'm really frightened, and I need reassurance, and I need to know what's going on.
Because if we respond to that complex behaviour at the start, at the burning ember, and you take five minutes to sit down and say, I can see you're really, really upset, you know, what's going on? I don't know where my mummy is. Well, tell me about your mummy. And you let the person talk about their mummy.
That emotional memory, as they're talking, helps them feel that love, that reassurance, and you're sitting there and you're holding their hand. And I know we're going to say there's challenges, because you're going to go over, you're going to get 5 or 10 minutes to do that. But when we ignore that, when we ignore that distressed behaviour, what you have is an 97 year old at the door, and there's seven staff and there’s security being called and we're reaching for pharmacological interventions and that is taking a lot of staff off the ward. It's going to cost our patient more time because we know that when we reach for pharmacological interventions, the person has a longer length of stay.
So we're loosing our patient's precious time as well. So don't ignore distressed behaviour. It is the patient trying to tell you there is something wrong. We need to look at those complex behaviours and others say that this is a symptom of a delirium. Actually, this is an indicator of what's going on.
So, if we've taken that five minutes that Orla mentioned to sit down and learn more about our patients with delirium, what do we then do with that information? Because information is only useful to other members of our team if it's passed on. Darren Bridges is the Mental Capacity Act lead for our trust and here he outlines why handovers matter so much when it comes to information relating to our patients with delirium.
So we're talking about understanding complex behaviours and we often see that some staff work really well with a patient. And they've got techniques and tactics that they use, but that's maybe not handed over to the next cohort of staff coming in, or it's not documented in terms of how we're managing that patient and how we're working effectively with them.
I know for me, reviewing like behaviour charts and things, and a lot of times I see ‘patient was agitated’. But we don't see what led up to that period of agitation. We don't see what that agitation actually presented like. Or how we resolved it. Yeah. So all we have now is one word documented somewhere and that's then used against that patient whenever it comes to the likes of discharge and looking at their behaviours.
All we have is they were ‘agitated’ but we don't know why they were agitated, how that presented or how we managed it. So I think it comes back to that whole idea of good care in terms of documentation, handover and making sure that if we find something that works for this patient. Everybody knows that and how we can look going forward in terms of management.
Here's Orla again. And that's why the life story booklets, they're live documents. You know, as you learn information, write it down. I have a lovely example of a wee lady who kept shouting in the middle of the night that she needed, I need a pooley, I need a pooley, I need a pooley, and nobody knew what it meant and it's actually, it's a Belfast colloquial word for the commode. So up in the Northern Trust they might not know that, you know. And once, once a nurse had caught on, like, she was actually asking for the toilet. So, it wasn't even, the lady did have a delirium, but she, she wasn't confused. She knew what she wanted.
She was telling us what we wanted and we weren't hearing it. We make presumptions about older people and people when they have a cognitive impairment like a delirium and I do recall caring for a patient who kept saying that her mummy would be down later and I was thinking this wee lady, you know, in her 70s that, you know, when she's saying her mummy will be down later.
And you could have picked me up at the floor that evening when her 92 year old mummy, who had had her when she was 18, came in to visit her daughter, and her mummy actually was indeed coming to the ward. So actually, you know, there's things that our patients tell us, and they're telling us exactly what it is, and we still don't even listen.
It can be hard to know where to start though, when it comes to finding the right words to say to a patient with delirium. If you're listening to this episode and you're a doctor or nurse, and you go into your ward tomorrow morning and you've got somebody who is wandering out of their side room and shouting in the middle of your ward round saying I want to go home, or maybe you have a confused male patient trying to walk into a female bay, what opening lines could we use with patients like these in order to try and settle the situation rather than flare it up? Back to Orla.
There are two sentences that we should really, really practice in our vocabulary. They're really easy. One starts with, ‘I can see that you're..’ and then your next bit is, ‘tell me about….’ and it's really, really that simple. The first is, validation therapy. ‘I can see that you're,,,’, but when you say to someone, ‘I can see that you're lost’, or ‘I can see you're worried’, or ‘I can see you're frightened, are you okay?’
You're immediately disarming the person, that you're immediately saying, I'm on your side, I know that there's something wrong, and I'm going to listen to you. Rather than waving your hand saying you can't go in here or don't be coming here. So if someone does look frightened, you're saying, ‘I can see that you're frightened, you know, tell me what's going on’.
And so that second question then, that ‘tell me about…’, is your distraction therapy, with reminiscence therapy underling it. So if someone is asking for their mummy, for their daddy, for their husband. That you would then say, ‘I can see you're, I can see you're really upset’, and they might go, I am upset, I don't know what's going on, don't know where I am, well, tell me why you're upset, well, I'm stuck in this place and I don't know where I am, then that could be the time, well, you're in the hospital and I'm a nurse, but if it's, I need to get home, I am annoyed I need to get home, I need to get home to your mummy. Well, tell me about your mummy, do I know your mummy, you know, what's her name, where does she work?
And in those conversations, and I might actually say, you might be able to say, I'm really enjoying listening to you, but my knees really sore, can we sit down? Come on over here and sit down and tell me about…, but you have to follow through, with the ‘tell me about…’, you have to deliver that reminiscence, you have to deliver the seeking reassurance bit, which means allowing the person to talk about the loved one that they're looking for, because it's only through that conversation, that reminiscence therapy, that they feel the love, and that's the opportune moment when you have the person then seated and settled to squeeze your hand and say, Well, you know, your mummy sounded amazing and I know she did a great job looking after you. We're going to look after you and I’m going to look after you, we’re in the hospital, Im a nurse and I’m going to look after you and that's when you would use your touch for, give their hand a wee squeeze, give them a wee hug. Yeah. ‘I can see that you're…’ and ‘tell me about..’.
But what if we've tried all of the strategies we talked about in the previous episode, and what we've already talked about here in episode four, with our reminiscence therapy, approaching somebody calmly, showing that we're on their side, saying, ‘I can see that you're, and tell me about.
And still, this person remains very agitated and unsettled, putting both themselves and others at risk of harm. At that point, It may be appropriate to look at using pharmacological therapy. So here's Jenny, a doctor working in psychiatry, to explain where we might go when we look at giving medications to patients.
I just want to say I feel inspired listening to Orla and Nicola. That's so helpful. And just to reiterate that not every patient with a delirium needs medication, but when you do get to that point, you may have a patient who's, because of the behaviour they're displaying, is posing a risk to themselves or to others on the ward.
And you are then, you've tried those other methods and you're now considering medication. Well, I would direct you to the delirium care pathway where the pharmacological interventions are listed there. This is where the evidence is at for the medication for managing these behaviours at the moment. The two medications that are listed there are an antipsychotic, haloperidol, generally you'd start that at 0.5mgs twice daily, and the alternative is lorazepam, again 0.5 mgs twice daily. We would advise using one agent at a time, again to avoid polypharmacy, which Julie spoke about earlier. And it's starting at the smallest dose and assessing, reassessing after you've done that to see, how the patient is. I'm just going to ask Julie to maybe highlight some of the reasons you may not use Haloperidol, you may use Lorazepam or somethings to consider whenever you're using it.
Here's Julie Magee. A pharmacist working in care of the elderly at Antrim Area Hospital. Like you were saying Jenny, Haloperidol is recommended in the NICE CG 103 guidelines because it's licensed for the acute treatment of delirium in adults where non pharmacological treatments have failed.
So Haloperidol is to be used first line, but if it's contraindicated, you can use lorazepam. It's contraindicated in those with Parkinson's, lewy body dementia, or people with a prolonged QTC. And again, like Jenny said, when these pharmacological agents are used, there should be a daily review, clear plans of titration and stopping them where possible, and they should be used at the lowest dose for the shortest time that they're needed for.
Why should we only give the lowest dose for the shortest time possible? You might ask, what's the harm in giving haloperidol if it keeps patients settled? Here's Julie again. There is an MHRA alert, safety alert, to remind prescribers of risks associated with haloperidol in older patients for the acute management of delirium.
Older people are at increased risk of neurological and cardiac effects with Haloperidol and they should be monitored for these. Some examples of the effects could be acute dystonia, tardive dyskinesia, Parkinsonism, dysphagia and hypersalivation. It's also important to remember to take a baseline ECG prior to initiating treatment with Haloperidol and the need for further ECGs during treatment is assessed on an individual basis.
Haloperidol can cause QTC prolongation and ventricular arrhythmias, and it's contraindicated then with medications that can also prolong QTC interval. For example, amiodarone, sotalol, citalopram, ecitalopram, clarithromycin, erythromycin, azithromycin, levofloxacin, that's just a few of them, and a full list of medications that prolong QTC can be found in the interactions section in the BNF.
It's also recommended that any electrolyte disturbances are corrected prior to starting Haloperidol and important to keep an eye on blood pressure as dose related orthostatic hypotension can occur in older people, which can then increase risk of falls.
Back to Jenny. Yeah, so just coming in on that, Julie, I think Orla said already, whenever you're prescribing a medication, just keeping in mind the potential risks of using that medication as well, such as falls, sedation. And just continuing to review that. We also would say if you're going to increase the dose of haloperidol, we would ask for a repeat ECG at that time as well, and just to review the QTC length.
These medications, as you will see on the delirium care pathway, can be prescribed orally, and they can also be given intramuscularly, IM. That would be a last resort if you were unable, if you had a severely agitated patient who was putting themselves or others at risk. Then that can be a route that can be used, but again, we would advise against you using that routinely.
Here's Stephen Johnson from the Mental Health Liaison Service again to explain why sedating medication should not be prescribed here, there and everywhere, but instead should only be used to manage risk. Here he is to explain what that means.
I think a really important aspect when prescribing medication, and in particular I'm thinking about any junior doctors who may be listening, is that the, the prescription of haloperidol and lorazepam is to deal with the behaviour itself. It's to limit the risk. It is not a magic bullet that will speed up the recovery of the delirium, and there's no strong evidence that it will reduce the duration of the delirium either, so it really is a case of we are trying to manage this patient in a given setting, and therefore whenever all the non pharmacological methods have been exhausted, well, there is a need to use a pharmacological method, but it is just about all of that risk. It won't absolve the person of their delirium.
One other perhaps important area just to touch on is that we often prescribe antipsychotics in line with NICE guidance for whenever there is significant risk to the patient or to others. And you can imagine how that sort of plays out in a ward setting. Where patients can have strange beliefs and given that they are so confused. One that comes up an awful lot whenever we come to see patients. with a delirium that's been difficult to manage would be that the hospital is in some way a meat factory. Or there's somewhere where other patients or people are coming to harm. And perhaps the patient can be quite fixed that one of their loved ones is somewhere in the building and is at great risk. And you can imagine just how distressing that is. And sometimes those individuals, they may not run to the door, they may not hit out at staff, but the degree of distress that they get from that fixed belief in the context of their delirium will often warrant use of an antipsychotic. You can just imagine going through that yourself and how difficult it would be to sleep, how difficult it would be to eat, thinking that your loved one was at serious risk of physical harm and nearby and you can't do anything about it.
Back to Orla with another question for Stephen. I'm interested in terms of, and maybe it's a complex question for now, but the use of PRN meds versus a STAT dose when maybe someone is in quite a distressed moment. Yeah, absolutely. Maybe just to touch on discontinuation first. Certainly for the vast majority of patients, they won't receive any medication for their delirium when they're in hospital.
And then for this minority who do require medication where there are risks. They receive medication, it resolves fairly quickly, as in their risk resolves fairly quickly, and therefore their medication can be reduced down and stopped quite quickly. There's a very small minority where, obviously, medication has been applied, it's being applied regularly, it's being built up.
And it's only at higher doses and with lots of reassurance and redirection where the patient even begins to become more manageable on the ward. And there's guidance around at that point when you might reduce back down again. Generally speaking, it's considered anywhere between 10 to 14 days, you would stay on the same dose of medication, ensure that there is a really good period of stability. And then it can be reduced down from there. And often for those patients, that might mean that they do go home on an antipsychotic or they do go home on lorazepam. But their GP can follow that up and reduce it down in the community.
So your other question there was about PRN medication. Yes, and this does come up quite a bit. I think it's entirely reasonable. Particularly at the beginning of a delirium for a patient where they might receive a one off dose of a PRN, where they may end up getting a good night's sleep and you might find that actually things resolve pretty quickly. For patients who, particularly when we turn up to review them, if we have noticed there's a pattern to the PRN medication, I'm thinking in the context of delirium that's often worse at night, and therefore, you will often see the medication being used at that time. Well then, it can be quite beneficial to just prescribe it regularly for a period, continue to review it on a very regular basis. And again, should be the lowest possible dose for the least possible time.
Over to Dr. Jackie Greer again. Just a quick reminder for folks that a lot of patients who develop delirium can have pre-existing conditions such as dementia. So before prescribing haloperidol, which is our first line agent, it's really important just to have a review of the Kardex because with more advanced dementia, some of these patients may already be on an antipsychotic agent such as risperidone or quetiapine, so initiating haloperidol on top of that medication may not be the right way to go, so just don't forget to have a little look at the Kardex.
Back to Stephen once more. In particular thinking about the cardiology wards for patients who have been admitted with a, with a stroke recently, sometimes haloperidol will not be your safest option, and sometimes using the, the lorazepam, which is also available on the delirium care pathway, can be a good starting point.
I think we may have talked before about the potential for lorazepam to have a paradoxical effect, where it can disinhibit patients or it may prolong the delirium, but it really is just a, a case of weighing the risks versus the benefits, for the patient and if there's any concerns about that, obviously that is a good junction to have a discussion with the psychiatry team that's covering your hospital.
So when do you refer to the mental health liaison team? I would say that the majority of patients I will never hear about. The majority of patients who have a delirium will be managed by their own medical team, will be managed very well by their own team and they will be discharged at a point where it's safe to do so even if the delirium is resolving and perhaps not entirely gone.
The point when you would refer to a liaison psychiatry service covering your hospital. Would be whenever the expertise within the medical team who's treating the patient has been, has been exhausted. So what that might practically look like is that the team have identified that this, this patient has become confused. They have utilized the delirium care pathway, which is available on the intranet and if they believe there is a risk to other patients in the ward or staff or a risk to the patient themselves, well then they may have begun to titrate medication.
So really it will vary from team to team. I would encourage all teams if you think a referral is necessary to have that MDT discussion first of all. Often a junior doctor on the ward round will come in and see a very settled patient because it's first thing in the morning. And they might not be aware that actually at night time when the individual's delirium has been much worse that there are risks and there are great difficulties in managing them.
There's also a varied degree of expertise in managing delirium. Obviously we have our medical consultants who do this day in, day out, and so feel very competent at it and therefore as it goes up the chain as such, through discussion, they will often be able to titrate haloperidol or perhaps switch to something like quetiapine very easily.
Whereas if we perhaps look at maybe our surgical wards or wards where delirium is, is less likely or less routinely managed. Then often those teams require a little bit more support. So when should we pick up the phone to get in touch with the Mental Health Liaison Service? What are the indications that mean a Mental Health Liaison referral is the right thing to do?
Some of the the main indications for coming to the Mental Health Liaison Service for advice or for assessment would be treatment resistance. So the delirium care pathway is really easy to follow. Perhaps you have started your patient on haloperidol and you have titrated it up and yet the patient is still running for the door, they're still pushing at people, they're still perhaps being aggressive towards other patients and there's a real sense that the team isn't getting on top of the management of the patient. And I suppose that's when we come. Often it's a It's a case of we will come, we will do a full assessment, we mentioned earlier in this episode about, well, why would a delirium not be resolving?
Often by doing a full psychiatry review, we're able to tease out a little bit of the background history and that's sometimes when we will stumble across that actually this is not just a simple delirium, that this individual has a dementia or that this patient did have a delirium and the delirium care pathway was the right way to start managing them, but actually the delirium's resolved, and there is an underlying psychosis that was there before he even entered the hospital, that has gone unnoticed.
And that's something that, in particular when you're managing a difficult patient, it can be really useful to talk to friends, family, get a collateral history, it's very helpful to pinpoint the diagnosis, but it also can be really helpful in those supportive measures of knowing what the patient is interested in, knowing what they respond to, you know, as a treating team, we often look after patients and we know them for a matter of days. a family member will have known this person for years and will know them in and out and be able to suggest really useful ways to manage them.
Some final thoughts from Orla on why it's always best to see what we can possibly do to prevent delirium rather than have it reach the point where it becomes complex and challenging to manage in the first place.
I think listening to the conversations today when we're thinking of the management of complex, prolonged delirium. It was actually highlighted to me how important it is to actually intercept at the beginning. You know, when we're thinking how do we prevent delirium and how do we recognize it and respond to it so much quicker because the outcomes aren't good, you know, we know the actual impact it has on a patient, the longer length of stay in hospital, increased falls in hospital setting, increased hospital acquired infections, increased morbidity, you know, and the less, the likelihood of getting back to your own place, your own residence, decreases dramatically when a delirium becomes complex.
So it is complex, so it's really great to have these conversations, but to me it just makes me think of when we focus on the start we really, really, you know, it's, we know it's much easier to prevent something than to try and de escalate something when it becomes complex. We really need to pull our boots up and get on board with preventing delirium, don't we?
Just before we wrap up today's episode, I want to bring back Darren Bridges, our Trust's Mental Capacity Act lead. When it comes to offering restrictive practices, whether that is chemical restraint by giving sedative medications or other forms of restraint, the Mental Capacity Act is something we must keep in mind.
This can be a very complex area, and one it's crucial we understand. Does the patient we are managing have capacity to make decisions in their own best interests? Do we need to have them placed on Enhanced Patient Clinical Observation, or EPCO? Lots to mull over, so here's Darren to help walk us through it.
So when we're looking at the Mental Capacity Act, at this point in time, we're looking at deprivation of liberty. And at the moment, what that means is the patient not being free to leave of their own choosing and under increased supervision and control. And really, whenever we look at patients with delirium and particularly those that are placed on EPCO, that's the majority of those patients that we're dealing with, that they are subject to that level of a deprivation of liberty.
And then it's really important that we're trying to uphold those service user rights, that we're protecting them and their human rights. But we're also protecting ourselves as staff from a legal perspective, and that's really making sure that all the safeguards are in place, that we know that we've assessed this patient's capacity to make sure that they can or cannot make decisions for themselves and that all our actions are being done in their best interest.
And best interest is a term that we throw around all the time, and it's very easy to say, but really what we're looking at in terms of best interest there is that it's the least restrictive. So we're talking about chemical restraint. And as we've talked about in this episode and the previous episode, there's lots of things we can do before chemical restraint that we should be trying first.
And we should be able to evidence and document how we've tried those things, how they haven't worked and how we've ended up where we are. And that's a real challenge. And it's something that the wards struggle to do and it's something that we struggle to do because we often are at crisis point where the patient's at the door, they're aggressive. We are struggling for what to do and that's when we, we reach for medication. But as we've been saying, there's so many things that we should have done in the build up to that point in time that could have potentially avoided us getting there.
In terms of the Northern Trust here in Northern Ireland, our main acute inpatient facility for patients with psychiatric illness Is Holywell Hospital, just outside Antrim. Darren outlines why patients with delirium on our wards on the most part, do not meet the criteria for moving here.
It's not the option and it's not the answer for us whenever it comes to delirium. And that's because of all the things that Jackie has talked about already in terms of the physical causes of delirium. This isn't coming from a place of a mental illness, it's coming from a physical cause that is leading to this acute illness. And the best place to treat a physical cause for something is in the acute hospital. It's not in a psychiatric unit. And there will be crossover. There will be times whenever we have patients who have a psychiatric illness and a delirium.
And that's where it takes really good collaborative work between our acute medical teams, our mental health liaison service, and the supports and services that we have within the acute hospital. To manage that patient as best we possibly can so they get the right treatment, at the right time, in the right place.
And we've seen that recently on the wards where we've had patients with a psychosis and a delirium superimposed on top. And it's about managing them on the ward until we can get that delirium under control and managed. Reassess the position at that point in time and then transfer over to a psychiatric unit as and when required.
And it's a very fine line. Legally, we're also talking about the repeal of the mental health order going forward with the Mental Capacity Act taking over. And it's a really turbulent time in terms of how we manage these patients from a legislation point of view. But I think everything we cover in this podcast goes back to the fundamentals of care.
And certainly within Mental Capacity Act and Mental Health Order, it's always about the least restrictive. It's always about the patient's best interest. It's always about upholding their rights. And I think if we're going back to PINCH ME, we're going back to good patient care, then we will conform to that legislation and we'll be doing the right thing by our patients and our service users going forward.
So much great advice to take on board there from our panel of experts because that is what they are. Let me just go around the table. Thank you Orla and Nicola and Stephen and Jenny and Darren and Jackie and Julie. Big, big crowd in here. And yeah, I genuinely feel like I have learned a lot from listening to you, so thank you very much for your time.
I think that That was probably an episode that I will go back and listen to again and I imagine it's one that would be helpful for us all to listen to remind ourselves how to deal with those patients who do seem slightly more challenging when we come across them in the wards.
And ultimately we want this podcast to be a resource that helps you in your work with patients who are experiencing delirium and we'd also love it to be something that you could share with your colleagues and friends wherever they might work.
Delirium is a real challenge and something that affects so many of our patients in the hospital setting. But as we've been seeing in the last two episodes, it is something that we can often manage and help treat if we take the right approach. So we really look forward to seeing you again when we come back for episode five next time when we will be discussing how to communicate about delirium with family members. Should be lots of fun, so make sure you don't miss it and we will see you then.