Introduction

Delirium is a worsening or change in a person’s mental state. Critically ill patients are subject to numerous risk factors for delirium (Girard, et al, 2008). It is a serious condition that is associated with poorer outcomes, an increase in hospital length of stay and risk of morbidity. Delirium can be hypoactive, hyperactive or a mix of both, each with its own signs and characteristics.

On occasion, Retrieve will transfer patients with acute confusion and delirium. This SOP outlines the assessment methods, describes practical considerations and provides guidance for maintaining patient and staff safety.

Confusion and pain assessment methods

Transferring a patient who is suffering from delirium or a level of confusion should be avoided unless it is absolutely necessary. The Confusion Assessment Method (CAM-ICU) is a validated tool for measuring delirium in intensive care (Appendix 1). It is quick, easy to perform and often used in combination with the Richmond Agitation-Sedation Scale (RASS) tool (Appendix 2). It consists of four features, designed to identify an acute change in mental state, inattention, a change in conscious level and disorganised thinking. Many intensive care units undertake CAM-ICU assessments daily and it is good practice to perform the screen any time there is a suspicion of altered or disordered mental status.

Prevention and management

The most powerful interventions for delirium are those that attempt to prevent, or at least minimise it, by modifying the risk factors. During transfer, there are a number of simple strategies that teams should use to achieve this.

Orientation

• Regular reassurance and orientation to date, time and place

Reversible factors

• Assess for hypoxia and optimise O2 saturations, if necessary and as clinically appropriate
• Address pain by using an assessment tool and looking for non-verbal signs of pain. Consider
• administering appropriate analgesia to the patient prior to departure

Modifiable factors

• Ensure patient is wearing hearing aids / glasses
• Environment
• Considered use of ambulance blue lights and sirens
• Utilise appropriate lighting in the back of the ambulance and consider use of window blinds
• Consider music via the radio if settling to patient

Transfer of patients with hyperactive or mixed delirium requires a minimum of two clinical staff to be present in the back of the ambulance. This will ensure that should the patient become increasingly agitated there are adequate personnel to immediately manage the patient and also communicate to the driver an unfolding situation which may require finding a safe place to stop.

Principles of restraint in law and UHBW policy

Delirious patients in a critical care environment are not in a position to give consent to the arrangements for them, either because of their condition or because of clinically necessary medication that they are being given.

A Deprivation of Liberty Safeguards (DoLS) following restraint of a patient in the ICU is not necessary, based on the case of Ferreira v Coroner of Inner South London (2017). It will only be in limited circumstances that arrangements in intensive care will give rise to a Deprivation of Liberty requiring formal authority [1].

The Mental Capacity Act 2005 includes multiple elements relevant to this SOP. Section 1; The principles states:

• (2) A person must be assumed to have capacity unless it is established that he lacks capacity.
• (3) A person is not to be treated as unable to make a decision unless all practicable steps to help him to do so have been taken without success.
• (4) A person is not to be treated as unable to make a decision merely because he makes an unwise decision.
• (5) An act done, or decision made, under this Act for or on behalf of a person who lacks capacity must be done, or made, in his best interests.
• (6) Before the act is done, or the decision is made, regard must be had to whether the purpose for which it is needed can be as effectively achieved in a way that is less restrictive of the person's rights and freedom of action

And Section 2, paragraph 1 states

• For the purposes of this Act, a person lacks capacity in relation to a matter if at the material time he is unable to make a decision for himself in relation to the matter because of an impairment of, or a disturbance in the functioning of, the mind or brain.

According to UHBW’s Mental Capacity Act policy, in order to decide whether an individual has the

capacity to make a particular decision you must answer two questions:

1. Is there an impairment of, or disturbance in the functioning of a person's mind or brain? If so,
2. Is the impairment or disturbance sufficient that the person lacks the capacity to make a particular decision?

The following key principles must be adhered to at all times:

• Restrictive interventions should never be used to punish or for the sole intention of inflicting pain, suffering or humiliation
• There must be a real possibility of harm to the person or to staff, the public or others if no action is taken
• The nature of the techniques used to restrict must be proportionate to the risk of harm and the seriousness of that harm
• Any action taken to restrict a person’s freedom of movement must be the least restrictive option that will meet the need
• Any restriction should be imposed for no longer than absolutely necessary
• What is done to people, why and with what consequences must be subject to audit and must be open and transparent
• Restrictive intervention should only ever be used as a last resort.
• People who use services, carers and advocate involvement is essential when reviewing plans for restrictive interventions

Professional judgement is fundamental in deciding upon the most appropriate course of action to ensure safe outcomes. Staff must justify a belief that immediate action is necessary to prevent a patient from significantly injuring him or herself, or it is clinically in the patient’s best interests. Staff will be required to account for their actions in all circumstances.

UHBW will always support employees who act in a way that is deemed reasonable and measured at the time of the incident, and where they have documented their decision-making and subsequent actions.

Clinical Standard Operating Procedure (SOP)

MANAGING DELIRIUM DURING TRANSFER

Version v1.0 From: 07/2022 – To: 07/2024 Author(s): Sîan Barke, Sam Heaton, Retrieve Leadership Team Page 2 of 7