175 Recognition and management of terminal delirium in a hospice inpatient unit

<h3>Background</h3> Delirium is an acute, encephalopathic syndrome of inattention, impaired consciousness and confusion.1 Delirium is the most prevalent neurological problem in patients with advanced illnesses. Indeed, de la Cruz et al. estimates 90% of inpatient hospice patients experience terminal delirium.2 While often irreversible, reversibility should always be considered. Despite its high prevalence, it is often misjudged as pain or missed entirely.3 The modified Richmond Agitation-Sedation Scale (mRASS) is a validated scoring system to aid recognising and objectively assessing delirium.4 We suspected practice in our hospice inpatient unit (IPU) could be more objective, so sought to assess the recognition and management of delirium in our IPU. <h3>Methods</h3> We reviewed all cases of terminal delirium over three months in our IPU. We assessed 1) whether reversible causes of delirium were considered by medical or nursing staff, 2) whether an mRASS was recorded, 3) Which medication was administered, and 4) if medication was administered, whether the response to the medication after 30 minutes was documented. <h3>Results</h3> Reversible causes of delirium were considered in 90% of cases. mRASS scores were documented in 0% of cases. In 80% of cases, midazolam was utilised, with haloperidol being used in the remaining 20% of cases. Response to PRN medication after 30 minutes was documented in 50% of cases. <h3>Conclusions</h3> This project highlighted that whilst consideration of reversibility was good, objective assessment prior to the use of pharmacological management using mRASS was poor. Medications used were felt to be appropriate but assessment of the response to medications was poor. We used this data to inform a separate Quality Improvement Project (Butler et al ‘ Improving recognition and management of terminal agitation in a hospice inpatient unit’). Work at sustaining improvement is ongoing.