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GUIDELINES FOR THE DIAGNOSIS AND MANAGEMENT OF OLDER PEOPLE WITH DELIRIUM

IN A GENERAL HOSPITAL SETTING

Version 2

Name of responsible (ratifying) committee MOPRS CSC Governance and Quality

Date ratified 05 February 2018

Document Manager (job title) Department of Medicine for Older People, Consultant Geriatrician, OPMH Consultant

Date issued 20 February 2018

Review date 19 February 2020

Electronic location Clinical Guidelines

Related Procedural DocumentsAcute Confusion Drug PolicyFalls Policy, DoLS Policy

Key Words (to aid with searching) Delirium; Confusion

Guidelines for the Diagnosis and Management of Older People with Delirium in a General Hospital settingVersion: 2. Issue Date: 20 February 2018Review Date: 19 February 2020 (unless requirements change) of 32

CONTENTS

1. INTRODUCTION................................................................................................................................42. PURPOSE..........................................................................................................................................43. SCOPE...............................................................................................................................................44. DEFINITIONS....................................................................................................................................45. DUTIES AND RESPONSIBILITIES...................................................................................................56. PROCESS..........................................................................................................................................5

6.1 Causes of Delirium....................................................................................................................56.2 Management of a patient with delirium.....................................................................................66.3 Capacity Assessment, the Mental Capacity Act, and DoLs....................................................116.4 Discharge arrangements.........................................................................................................126.5 Prognosis................................................................................................................................12

7. TRAINING REQUIREMENTS..........................................................................................................128. REFERENCES AND ASSOCIATED DOCUMENTATION...............................................................129. MONITORING COMPLIANCE WITH, AND THE EFFECTIVENESS OF, PROCEDURAL

DOCUMENTS...............................................................................................................................14APPENDIX I: FLOW CHART FOR THE MANAGEMENT OF DELIRIUM...........................................15APPENDIX II: MONTREAL COGNITIVE ASSESSMENT (MOCA).....................................................16APPENDIX III: ABBREVIATED MENTAL TEST SCORE (AMT)........................................................17APPENDIX IV: SOME OF THE DRUGS / GROUPS THAT MAY PRECIPITATE DELIRIUM.............18APPENDIX V: DELIRIUM AUDIT TOOL..............................................................................................19APPENDIX VI: DELIRIUM INFORMATION FOR PATIENTS AND RELATIVES ..............................21APPENDIX VII: THE CONFUSION ASSESSMENT METHOD (CAM) ...............................................24APPENDIX VIII: THE 4AT TEST.........................................................................................................25APPENDIX IX: PLAN OF CARE FOR MANAGING A PATIENT WITH DELIRIUM.............................27EQUALITY IMPACT SCREENING TOOL...........................................................................................29


1. INTRODUCTION

Delirium is common in hospitalised patients with a range between 10 and 50% reported in different studies1,2,3. It occurs most frequently in those with dementia and older people (up to 30% of older inpatients) but also commonly in Intensive Care Unit (ICU) patients4, in the alcohol dependent 5 and in the terminally ill6. It can occur in a wide variety of medical situations.

Delirium is often not recognised by clinicians (missed in up to 2/3 of cases) and is frequently poorly managed7. Lack of recognition is important and may occur for a number of reasons including the fluctuating nature of it, overlap with dementia, lack of collateral history and formal cognitive assessments being used, failure to appreciate the clinical consequences and failure to consider the diagnosis important7.

It is vital that delirium is recognised and appropriately managed because patients who develop delirium have high mortality (twice as likely to die), institutionalisation and complication rates, and have longer lengths of stay than non-delirious patients (up to 8 days has been described)8. There is potential to prevent the onset of delirium in up to 30% of older in-patients9, 10. The National Service Framework for Older People (DOH 2001)11 identifies a fundamental requirement for the NHS to ensure the good and effective management of patients with mental health needs wherever they are being cared for. The NICE Clinical Guideline (CG103) – Delirium: prevention, diagnosis and management, also emphasises that it is a serious condition that is associated with poor outcomes, and focuses on preventing delirium in people identified to be at risk.

This document has been designed to assist clinicians in the achievement of this standard. The guidance contained within this document has been developed in line with the Guidelines for the Prevention, Diagnosis and Management of Delirium in Older People, Royal College of Physicians, 200612, and also draws on the guidelines from the Isle of Wight Healthcare Trust 200513, and NICE CG 10338

Note: Clinician is used in reference to Doctors, Nurses and all members of the Multi-disciplinary team (MDT)

2. PURPOSEThe following guideline aims to provide support for clinicians in the recognition, diagnosis and management of older people presenting with the symptoms of Delirium within the acute hospital environment, it is important to remember that patients with delirium can be found in all specialties of the hospital. These guidelines do not specifically cover the management of withdrawal of alcohol (see separate policy)

3. SCOPEThis document is intended for the use of all staff involved in the care of patients identified as at risk or with a confirmed diagnosis of Delirium.

The primary focus of the document has been developed around the care of older people, who are particularly prone to developing this condition. However the guidance may also be broadly applied to the treatment of acute confusion in younger patients.

4. DEFINITIONSSince its inclusion in the Diagnostic and Statistical Manual of Mental Disorder (DSM) in 1987,

Delirium has been the consensus term for the syndrome although it is also known as acute confusion. The diagnostic criterion for delirium has been revised in the latest DSM- 539


https://www.nice.org.uk/guidance/cg103

Delirium is defined as a disturbance in attention and awareness that develops over a short period of time and tends to fluctuate due to a cause such as a medical condition, drug withdrawal or multiple aetiologies.There are 5 core criteria

Disturbance in attention (i.e. reduced ability to direct, focus, sustain and shift attention) and awareness (reduced orientation to the environment).

Disturbance develops over a short period of time (usually hours to a few days), represents an acute change from baseline attention and awareness, and tends to fluctuate in severity during the course of the day.

An additional disturbance in cognition (e.g. Memory deficit, disorientation, language, visuospatial ability, or perception)

The disturbances are not better explained by a pre-existing, established or evolving neurocognitive disorder and do not occur in the context of a severely reduced level of arousal such as a coma

There is evidence from the history, physical examination or laboratory findings that the disturbance is a direct physiological consequence of another medical condition, substance intoxication or withdrawal, or exposure to a toxin, or is due to multiple aetiologies.

There are several subtypes of delirium recognised. These are hyperactive (pulling at clothing, restless, wandering, aggression); hypoactive (more common, sleepy, difficulty following conversation, behaviourally not difficult and therefore the most common type to be missed) or a mixed picture where the patient may fluctuate between the two types described above17. Delirium may also be subsyndromal – i.e. not meeting the full criteria for depression. The latter may occur when the patient is recovering but not yet fully recovered.

It is important to recognise behaviours and symptoms that can be associated with an underlying delirium which include:

illusions/hallucinations (commonly visual, but can be in any modality) delusions and misinterpretation of events mood changes (including depression and hypomania) psychomotor disturbances as outlined above altered sleep wake cycle disorientation restlessness wandering stripping off clothes verbal aggression physical aggression refusal to eat/drink disinhibited behaviour including sexual disinhibtion incontinence an inability to co-operate or participate in care17.

5. DUTIES AND RESPONSIBILITIESDetail the duties, accountabilities and responsibilities (including level) of Directors, individuals, specialist staff, departments and committees.

It is the responsibility of all clinical staff involved in the caring for patients with Delirium to follow the recommendations of this guideline.

It is the responsibility of the Consultants, Matrons and Divisional Nurses to ensure that systems exist to enable staff to receive the training they require.


6. PROCESS6.1 Causes of DeliriumUp to a third of delirium is preventable9,16. Therefore awareness of risk factors, likely precipitating factors and the appropriate avoidance of these wherever possible are essential to reduce the development of the syndrome. Delirium is usually the result of the complex interaction of multiple conditions and risk factors. There is often a balance between risk factors and precipitating factors. For example, an older person with dementia may only require a relatively minor precipitant to become delirious, whereas in a young and usually fit person a major precipitant, such as severe sepsis, would need to occur before that person developed delirium. Table 118,19, outlines some of the major known risk factors and possible precipitants of delirium. These are not exhaustive lists.

Table 1. Risk factors and precipitating factors

Risk Factors Common precipitating factors for delirium

Older age Existing chronic cognitive impairment or

dementia Post general anaesthesia Pain Polypharmacy Renal impairment Hepatic impairment Drug/ Alcohol withdrawal Surgery e.g fracture neck of femur Significant environmental change Multiple co-morbidities Sensory impairment such as deafness,

visual problems Previous episode(s) of delirium

Infection Drugs (any, but particularly

psychoactive drugs and drugs with anticholinerigic properties or opiods)

Immobility, including the use of physical restraint

Use of bladder catheter Constipation Urinary retention Malnutrition Dehydration Electrolyte disturbance Hypoxia Pain Metabolic disturbance Severe illness Environmental change (ward transfer,

lack of clock/watch) Sensory deprivation (hearing aid not

working, glasses dirty/missing etc)

(Adapted from Inouye et al 1993 and Inouye 2000)

6.2 Management of a patient with deliriumThis should include:-

Recognition of the condition Identification of underlying causes Treatment of underlying causes Management of the confusion and behaviour associated with delirium

Recognition of the condition Diagnosing delirium can be difficult, and as previously highlighted, the diagnosis is frequently missed. In view of this the following are suggested12:

Collateral information, to include prior cognitive status wherever possible, should be sought from all available sources to include the patient’s carer or supporter, GP or anyone who knows them well. This is an essential step as people who know the person well are the best judge of whether they are different from their baseline. They often are well placed to notice fluctuations in the patient’s mental state whilst they are in hospital.


Cognitive testing should be carried out on all older patients on to admission hospital and be entered into the patient’s notes.

Serial measurements in patients at risk may help detect the new development of delirium or its resolution.

Clinicians are encouraged to make an initial assessment of the cognitive function by the use of a recognised screening tool such as the: Montreal Cognitive Assessment (MoCA see Appendix II), or the Abbreviated Mental Test score (AMTS see Appendix III).

However cognitive tests by themselves cannot distinguish between delirium and other causes of cognitive impairment. Dementia and delirium frequently occur together and it can be particularly difficult to distinguish between them when a patient presents acutely. It is frequently the situation that underlying confusion from dementia is worsened by an episode of delirium. IT SHOULD BE ASSUMED THAT ALL PATIENTS PRESENTING ACUTELY WITH CONFUSION ARE DELIRIOUS UNTIL PROVEN OTHERWISE TO AVOID TREATABLE CONDITIONS BEING MISSED.

The Confusion Assessment Method (CAM) can be used to formally diagnose delirium (see Appendix VII).Alternatively the 4AT is an assessment test for delirium and cognitive impairment (see Appendix VIII)Both can be used throughout hospital stay to assess for delirium and monitor improvement.

In many cases patients suffering from Delirium will be unable to provide a complete and detailed history. Therefore an exploration of pre-admission state from a relative or carer may prove invaluable and is an essential part of the assessment.

Having established a baseline, further serial measurements should be undertaken as a means to detect any improvement or deterioration in the status of cognitive function (suggested at least twice a week or when there are significant changes in the condition). Visitors such as the patient’s relatives / carers are also well placed to comment on the patient’s mental state, cognition and behaviour in hospital, including fluctuations in cognition. They will also be able to gauge improvement and to know when they are back to their baseline. Others who have close contact with the patient, such as staff nurses, healthcare support workers and cleaners are also good sources of information about the day to day presentation and progress of the patient.

Identification of the underlying cause(s)HistoryCommon causes of delirium include any physical illness, medication (particularly those with anticholinergic side effects and opiates) or withdrawal from alcohol or drugs23. See appendix IV for a list of some of the drugs that may precipitate delirium.

Many patients with a confused state are unable to provide the necessary information. Therefore information should always be sought from someone who knows the patient well to contribute to a more comprehensive assessment.

In addition to standard questions in the history, the following information should be specifically sought.

Full drug history including non prescribed drugs and recent changes. In hospital the full drug chart should be examined, including the “as required” medication section.

Alcohol and substance history Benzodiazepine use (avoid rapid withdrawal) Previous intellectual function (e.g. ability to manage household affairs) Functional status (e.g. activities of daily living) Onset and course of confusion Previous episodes of acute or chronic confusion Symptoms suggestive of underlying cause (e.g. infection)


Sensory impairments Bowel habits

ExaminationPhysical examination can be difficult and may be needed to be completed in stages. Be aware of your approach to the patient (see section 7.4 management of confusion). Full examination should be undertaken with particular reference to the following:

Neurological examination, level of consciousness Nutritional status (clinical evidence plus MUST score) Clinical evidence of dehydration Evidence of pyrexia or hypothermia (beware that older patients with sepsis do not always

mount a pyrexia) Evidence of alcohol/ substance use or withdrawal PR Examination for constipation Bladder scan to exclude urinary retention Cognitive function using a standardised screening tool e.g AMTS, MoCA

InvestigationsThe following investigations are almost always indicated in patients with delirium in order to identify the underlying cause:

Full blood count, C Reactive Protein, urea and electrolytes, calcium and phosphate, liver function tests, glucose

Chest X-ray and pulse oximetry ECG Urinalysis Thyroid function tests (if not done within the last six months)

Other investigations may be indicated according to the findings from the history and examination.These include:

Blood cultures, B12 and folate, Magnesium, Arterial blood gases, Specific cultures eg urine, sputum

CT head (see below) Lumbar puncture (see below) EEG (see below)

CT Scan Although many patients with delirium have an underlying dementia or structural brain lesion (e.g previous stroke), CT has been shown to be unhelpful on a routine basis in identifying a cause for delirium18 and should be reserved for those patients in whom an intracranial lesion is suspected.Indications for the use of CT scanning should be discussed with a senior clinician (SpR level or Consultant)

Focal neurological signs Confusion developing after head injury Confusion developing after a fall Evidence of raised intracranial pressure

Lumbar punctureRoutine Lumbar puncture is not helpful in identifying an underlying cause for the delirium24. It should therefore be reserved for those in whom there is reason to suspect a cause such as meningitis or encephalitis. This might include patients with the following features:

Meningism Headache and fever


EEGAlthough the EEG is frequently abnormal in those with delirium, showing diffuse slowing25, its routine use as a diagnostic tool has not been fully evaluated. However it can be useful when a medical cause cannot be found; if the EEG is abnormal it will identify encephalopathy and therefore the need to carry on looking for a cause

EEG may also be useful where there is difficulty in the following situations (after discussion with an Spr or Consultant):

Differentiating delirium from non-convulsive status epilepticus and temporal lobe epilepsy Differentiating delirium from dementia Identifying those patients in whom delirium is due to a focal intracranial lesion

Treatment of underlying cause

The most important approach to the management of delirium is the identification and treatment of underlying cause(s). It is common for there to be more than one contributing factor. Therefore it is important that all possible causes are actively managed concurrently, and that you continue to look and then treat further underlying causes.

Incriminating drugs should be withdrawn wherever possible26. Many drugs can precipitate delirium (e.g. opiates and drugs for treating Parkinson’s disease) and any recent changes/additions should be considered a possible contributing factor. Appendix IV outlines some of these but is not exhaustive. Always remember to look at the PRN side of the medication chart, as guilty drugs are often to be found there.

Drugs with anticholinergic activity (many drugs in common use, including benzodiazepines, have some anticholinergic effects and it is not always possible to avoid them all and their contribution to delirium should be balanced with their other required effects.) Appendix IV outlines some drugs that may precipitate or worsen delirium, many of them through anticholinergic activity

Correct biochemical abnormalities promptly27 Correct hypoxia Treat pain Treat underlying infection (please refer to the guidelines from Microbiology with regard to

potential prescription of antibiotics). Avoid constipation – monitor bowel habit daily and where constipation is identified, treat it

robustly Avoid catheters where possible, but be vigilant for urinary retention

When no cause can be found, or when delirium is not resolving despite treating the underlying cause, go back and look again for another cause.

Management of Confusion

Non Pharmacological Management

Consider involvement of the Dementia Case workers to support the ward and patient.

In addition to treating the underlying cause, management should also be directed at the relief of the symptoms of confusion/delirium. The patient should be nursed in a good sensory environment with a multi-disciplinary approach to individualised care7,8,9,16,18,28-33.

This includes:-

Improve communication


Be aware of the person’s life biography – this may give you cues for conversational topics and prevent anxiety. Use the “This is Me” document as a prompt to work with their family, carers or friends to help find out about the person’s background and interests.

Verbal – Do not confront. Confused people are more likely to become agitated and aggressive if they feel threatened. Communicate clearly, calmly, simply and express your wish to help with their situation to reduce their distress/confusion.

Introduce and personalise yourself to the person. Listen to the person, observe the behaviour and try to interpret the message, emotion and

feelings being communicated. Try to avoid commands and the words ‘don’t’ and ‘why’. For example if a patient at risk of

falling repeatedly tries to get up, don’t say “I told you not to get up”. Rather, if possible assign someone to walk with them to ensure their safety, or if that is not possible, try to distract them (see below).

Explain to the person what you want them to do – not what not to do. Acknowledge their feelings and show concern. More than one member of staff talking to the person at the same time will add to the

confusion and lose the thread of intervention. It may also serve to make the person feel threatened.

If appropriate, try to orientate the person and highlight visual clues for them to acknowledge, e.g. show other patients in beds. If the patient insists they are somewhere else, validate/acknowledge their feelings and do not proceed with reality orientation as this could provoke a confrontation..

Engage with the person in meaningful interaction by offering distraction and diversions, such as reading a newspaper with them, playing a game, doing a jigsaw or asking them about their career or their upbringing.

Explain unfamiliar noises/equipment/personnel to the person to avoid misinterpretation. Do not label a person or their behaviour in a negative way to others. Where appropriate, explain to the patient and their relatives/carers about their diagnosis of

delirium, and give written information to help them understand what is happening to them.

Non-verbal – Open-handed gestures are seen as non-threatening, whereas pointed gestures are invariably seen as aggressive. Offering a handshake will be recognised by a confused person as a friendly gesture. If a person refuses to shake hands, this may indicate to the nurse that hostility and potential aggression are likely. Approach the person from the front, slightly off-centre to avoid feelings of confrontation. Maintain good eye contact and initial distance of approx. three feet, so as not to invade

personal space. If the person is in bed or seated, avoid standing over them and, where possible, crouch

down to their eye level. Non-verbal clues such as facial expression, body posture and eye contact will be taken on

board by the patient and will override verbal communication

Favour high-quality sleepNon pharmacological sleep promotion; noise reduction; use of low level lighting; avoidance of constant lightening; maintenance of a normal sleep-wake cycle. If liked use milky drinks at bedtime.

Limit sensory underload or overloadScreen for visual and hearing impairment; provision of visual and hearing aids; Lighting level appropriate for time of day; avoidance of rooms with no windows. Where possible elimination of unexpected and irritating noise e.g. pump alarms.

Involve and inform significant others Explain the cause of the confusion to relatives. Encourage family to bring in familiar objects and pictures form home and participate in rehabilitation


Avoid malnutrition and vitamin deficiencies Nutritional support and/ or vitamin supplements of high-risk groups. Good diet, fluid intake and mobility to prevent constipation.

Favour mobilisation Avoid immobilisation. Limit the use of catheters and intravenous lines. Encourage early mobilisation and evaluation by a physiotherapist if appropriate.

Check the physical needs of the patientDo they need to use the toilet, are they hungry, thirsty, constipated, in urinary retention, or in pain?

“Wandering”In many cases, what is referred to as “wandering” is just a normal desire to walk and be active. Wherever possible, people should be safely supported to walk around the ward (and hospital if appropriate). Preventing them from doing so is likely to lead to agitation and possibly aggression. People wander for a variety of reasons.

Environment

Inter and intra ward transfers should only be considered for clinical management reasons. Transferring patients with delirium will add to their confusion and disorientation and therefore should be avoided. Specifically patients with delirium should NOT be moved to outlying areas without senior medical consultation (SPR and above).

For an example plan of care for managing a patient with delirium see Appendix IX

Pharmacological management of confusion

For information on drug use refer to drug guidelines- Guideline on Drug Management of delirium and behavioural disturbances in the older person (65yeras and over) in Hospital

Drug sedation may be necessary in the following circumstances12 In order to carry out essential investigations or treatment To prevent the patient endangering themselves or others To relieve distress in a highly agitated and/or hallucinating patient

6.3 Capacity Assessment, the Mental Capacity Act, and DoLs

Legal AspectsPlease note that if the patient does not have capacity to make a decision about medical treatment then the decision to treat should be made using the process of Best Interests decision-making under the Mental Capacity Act 2005. Further details are given in the Mental Capacity Act Policy. It is crucial to thoroughly document your capacity assessment and best interests decision.

Under the Mental Capacity Act 2005, someone lacks capacity when the following criteriaare met:

Does the person have an impairment of, or a disturbance in, the functioning of themind or brain? If yes, then continue to ask:Does the impairment or disturbance mean that the person is unable to make aspecific decision when they need to? For this test, a person is unable to make adecision (i.e. lacks capacity) if they cannot:Understand information about the decision to be made;Retain information about the decision to be made;Use or weigh that information as part of the decision-making process;


http://pht/Departments/Pharmacy/Drug%20Therapy%20guidelines/Delirium%20and%20Behavioural%20Disturbance%20in%20the%20Older%20Person%20(65%20years%20and%20over)%20in%20Hospital.doc

http://pht/Departments/Pharmacy/Drug%20Therapy%20guidelines/Delirium%20and%20Behavioural%20Disturbance%20in%20the%20Older%20Person%20(65%20years%20and%20over)%20in%20Hospital.doc

Communicate their decision.

In summary:

1) Always assess a patient’s capacity to consent to (or to decline) interventions / medication2) Where a patient lacks capacity, a best interests decision should be made, using the best interests checklist of the Mental Capacity Act. Where possible, a family member of carer should be consulted. 3) If restraint is needed in order to administer medications or for any other reason, then for someone who lacks capacity to consent you should follow the principles of the Mental Capacity Act, in other words restraint must be necessary to prevent harm, and proportionate to the likely harm. You should demonstrate that this is the case by documenting it. If restraint is prolonged or being used repeatedly then the Mental Health Act should be considered. Where a person has capacity, if restraint is essential to prevent immediate harm, then the common law may apply during the immediate crisis. If it remains necessary and the person has a mental disorder, the Mental Health Act should be considered. Otherwise restraint is illegal in someone who has capacity.

Deprivation of LibertyGiving medications against a patient’s will (whether orally or intramuscularly), especially using restraint, is a strong indicator that someone is being deprived of their liberty. Where someone is deprived of their liberty, there must be a legal power (deprivation of liberty safeguards (DoLS) or the Mental Health Act) to authorise the detention. The Mental Capacity Act allows for restraint and emergency treatment under certain circumstances; however for persistent situations where medication is repeatedly given against someone’s will and/or restraint occurs repeatedly, it is very important to urgently consider which legal framework is needed to authorise the deprivation of liberty. In practice the Mental Health Act should be used for persistent situations where a patient is objecting to the treatment they are being given and/or their admission. Please see DoLS guidelines and Mental Health Act Policy.

If the patient is assessed as lacking the capacity to make the decision to consent to hospital admission the Clinician will need to apply for a Deprivation of Liberty safeguard (DOLs) – see PHT policy for the up to date information40

If a health professional needs to sedate a patient without capacity then they should document theirassessment of the patient’s mental capacity in the medical records, document why the intervention is in the patient’s best interests using the best interests checklist and date, time and sign the entry. At present if a patient is requiring any sedation or chemical restraint PHT have asked that a safety learning event is completed, to facilitate a review of the patients’ management. This restraint will also need to be reflected in the DOLs application.

Mental Health Liaison Team are available within the hospital for advice and support on patient management and medication. Referral is via extension 4074.

6.4 Discharge arrangements

The discharge documentation should clearly state that the patient has had an episode of delirium and all the likely precipitants of this. Cognitive testing should be done close to discharge (AMTS or MoCA) and recorded on the discharge documentation. Some patients with delirium may be traumatised by the experience12 and their family or carers may have been frightened by the episode of delirium, and where possible the diagnosis should be explained to the patient (and/ or next of kin where appropriate) and verbal support and advice offered. Appendix VI outlines some information from the Royal College of Psychiatrists 36 which may be useful for patients who have experienced delirium and their relatives. It emphasises the importance of spending time with a patient who has experienced delirium and their family to explain to them what has happened and why which can be of relief to patients.


http://www.porthosp.nhs.uk/about-us/policies-and-guidelines/policies/Clinical/Deprivation%20of%20Liberty%20Safeguards%20Policy.doc

http://www.porthosp.nhs.uk/about-us/policies-and-guidelines/policies/Clinical/Deprivation%20of%20Liberty%20Safeguards%20Policy.doc

http://www.porthosp.nhs.uk/about-us/policies-and-guidelines/policies/Clinical/Mental%20Health%20Act%20Policy%20for%20Adults%20aged%2018%20and%20over.docx

http://www.porthosp.nhs.uk/about-us/policies-and-guidelines/policies/Clinical/Restriction%20and%20Restraint%20in%20Adult%20Care%20Policy.doc

http://pht/Departments/safeguarding-adults/Mental%20Capacity%20Act%20MCA/Best%20Interest%20Checklist%20-%20Feb%202017.doc

6.5 PrognosisIn many people, delirium may take weeks or months to fully recover (in about half of cases there are persistent symptoms at 1 month and in 20% of cases some symptoms remain at six months). It is important to inform the patient and their relative of this fact. Furthermore, for those who have suffered delirium on a background of no or minimal cognitive impairment, they have a 40% chance of developing dementia in the next two years. For those who already have dementia, delirium is often associated with a worsening of their cognition and functioning.

7. TRAINING REQUIREMENTSAll staff will need to show evidence of having read the guideline. Each department will need to evidence a roll out program for the guideline supported by inter-department training.

8. REFERENCES AND ASSOCIATED DOCUMENTATION

8.1 References1. Bhat, R.S., Rockwood, K. (2002). The prognosis of delirium. Psychogeriatrics, 2 (3): 165-179.2. Francis J, Martin D, Kapoor WN. (1990). A prospective study of delirium in hospitalized

elderly. JAMA; 263:1097-1101.3. Lindesay, J., Rockwood, K. and Rolfson, D. The epidemiology of delirium. In Delirium in Old

Age. Eds. Lindesay, J., Rockwood, K., Macdonald, A. (2005). Oxford University Press; 2002 pp 27-50.

4. Jackson, J.C., Mitchell, N, & Hopkins R.O.(2009) Cognitive functioning, mental health, and quality of life in ICU survivors: an overview .Critical Care Clinics. 25:3 615-628.

5. DeBellis, R, Smith, BS, Choi, S & Malloy, M. (2005). Management of Delirium Tremens. Journal of Intensive Care Med.

6. Plonk, W M Arnold R M. (2005). Terminally ill. Journal of palliative medicine. 8:1042-10547. Young L & George j (1999) Guidelines for the management of Delirium in the Elderly. British

Geriatric Society: London. 8. Marcantonio (2002) The management of delirium. In Delirium in Old Age. Eds. Lindesay, J.,

Rockwood, K., Macdonald, A. Oxford University Press. p.p. 123-151.9. Marcantonio, E.R., Flacker, J.M., Wright, R.J., Resnick, N.M. (2001). Reducing delirium after

hip fracture: a randomised trial. JAGS 2001; 49: 516-522.10. Inouye, S.K., van Dyck, C., Alessi, C.A., Balkin, S., Siegal, A.P. and Horwitz, R.I.(1990)

Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Annals of Internal Medicine;113: 941-8.

11. The national service framework for older people. (2001) Department of Health. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4003066

12. British Geriatrics Society (2006) Guidelines for the prevention, diagnosis and management of delirium in older people in hospital. Retrieved September 2006, from the British Geriatric Society website: www.bgs.org.uk

13. Peck, S. (2005) (2nd Ed) Clinical Guideline for the are and Treatment of OlderPeople with Delirium in a General Hospital Setting. Isle of White Healthcare NHSTrust.

14. Siddiqi N, Stockdale R, Britton AM, Holmes (2007) Interventions for preventing delirium in hospitalised patients. Cochrane Database of Systematic Reviews. Issue 2:CD005563

15. Inouye SK, Bogardus ST, Charpentier PA, Leo-Summers L, Acompora D, Holford TR and Cooney LM. A multi-component intervention to prevent delirium in hospitalised older patients. NEJM 1999; 340:669-676

16. Britton AM,Hogan-Doran JJ Siddiqi N (2006) Multidisciplinary Team interventions for the management of delirium in hospitalized patients (protocol). The Cochrane database of systematic reviews. Issue 2:CD005995

17. Inouye S, Viscoli C, Horowitz R, Hurst L, Tinetti M. A predictive model for delirium in hospitalized elderly medical patients based on admission characteristics. Ann Int Med 1993;119:474-481.

18. Inouye, S. Prevention of delirium in hospitalised patients. Journal of General Internal Medicine.2000;13: 204 – 212.


http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4003066

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4003066

19. Folstein M, Folstein S, McHugh P. “Mini Mental State”: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975; 12: 189 – 198.

20. Jitapunkul S, Pillay I, Ebrahim S. The abbreviated mental test: its use and validity. Age & Ageing 1991;20:332-336.

21. Warshaw G, Tanzer F. The effectiveness of lumbar puncture in the evaluation of delirium andfever in the hospitalized elderly. Arch Family Med 1993;2:293-297.

22. Jacobsen SA, Leuchter AF, Walter DO. Conventional and quantitative EEG in the diagnosisof delirium among the elderly. J Neurology, Neurosurgery and Psychiatry 1993;56:153-158.

23. Casarett, D.J., Inouye, S.K. Diagnosis and Management of Delirium near the end of life. Ann. Intern. Med 2001;135: 32-40.

24. George, J., Bleasdale, S. and Singleton, S.J. Causes and prognosis of delirium in elderly patients admitted to a district general hospital. Age and Ageing 1997; 26: 423-427.

25. Landefield CS, Palmer RM, Kresevic DM, Fortinsky RH, Kowel J. A randomized trial of carein a hospital medical unit especially designed to improve the functional outcomes of acutely ill older patients. NEJM 1995;332:1338-1344.

26. Milisen, K., Foreman, M.D., Abraham, I.L., DeGeest, S., Godderis, J., Vandermeulen, E., Fischler, B., Delooz, H.H. A nurse led interdisciplinary programme for Delirium. JAGS 2001;49 (5): 523-532.

27. Philp I,and Appleby L Securing better mental health for older adults. 2005. Department of Health, London

28. Lundstrom, R.N., Edlund, A., Karlsson, S., Brunnstrom, B., Bucht, G., Gustafson, Y. A multifactorial intervention program reduces the duration of delirium, length of hospitalisation and mortality in delirious patients. JAGS 2005; 53: 622-628.

29. Britton, A., Russell, R. (2003). Multidisciplinary team interventions for delirium in patients with chronic cognitive impairment (Cochrane Review) in The Cochrane Library, Issue 4; Chichester UK: John Wiley and Sons Ltd.

30. McClusker, J., Cole, M., Abrahamowicz, M., Han, L., Podoba, J., Ramman-Haddad, L. Environmental risk factors for delirium in hospitalised elder people. JAGS 2001; 49: 1327 – 1334

31. Naughton, B., Saltzman, S., Ramaan, F., Chadha, N., Priore, R., Mylotte, J. A multifactorial intervention to reduce the prevalence of delirium and shorten hospital length of stay. JAGS 2005; 53: 18 – 23.

32. O’Keeffe, S.T. Down with bedrails? Lancet 2004; 363; 343-433. Mental Capacity Act (2005) the Stationery Office London34. Featherstone, I & Hopton, A (2007). Stop Delirium! Liaison Psychiatry for Older People

Conference.35. Delirium Factsheet (2009). Royal college of Psychiatrists. Retrieved Nov 2009, from the Royal

college of Psychiatrists website: http://www.rcpsych.ac.uk/mentalhealthinfo/problems/physicalillness/delirium.aspx

36. Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion assessment method. Am Coll Phys 1990;113:941-8

37. NICE Clinical Guideline CG103 https://www.nice.org.uk/guidance/cg10338. Diagnostic and Statistical Manual of Mental Disorder (DSM)-5

https://www.psychiatry.org/psychiatrists/practice/dsm39. Deprivation of Liberty of Safeguarding Policy

8.2 Relating policy and guidelines – to read in association with this guideline Decision-making for people who lack mental capacity Policy Acute confusion and aggression in Older People on Medicine for Older People wards –

Guidelines on management Clinical policy & associated guideline for the assessment, prevention and management of

adult in-patients at risk of falling or who have already fallen Clinical policy for the use of bedside rails Acute Alcohol withdrawal


https://www.psychiatry.org/psychiatrists/practice/dsm

https://www.nice.org.uk/guidance/cg103

http://www.rcpsych.ac.uk/mentalhealthinfo/problems/physicalillness/delirium.aspx

9. MONITORING COMPLIANCE WITH, AND THE EFFECTIVENESS OF, PROCEDURAL DOCUMENTS

A base line audit (appendix V) should be completed before implication of the guideline and a subsequent audit should be completed every six months to ensure that standards are improving. The responsibility for monitoring should be identified with in each department and audit reports fed in to divisional governance structures.


APPENDIX I: FLOW CHART FOR THE MANAGEMENT OF DELIRIUM


PATIENT IDENTIFIED WITH POSSIBLE ACUTE CONFUSION/DELIRIUMMAKE A COGNITIVE ASSESSMENT – AMTS/MoCA/CAM

Confusion is a symptom not a diagnosis. Delirium/acute confusion can occur in a patient with known dementia. Delirium is dangerous (mortality and institutionalisation doubled, LOS increased). Delirium can be treated. Delirium may be the only manifestation of significant acute disease in an older person

Appendix II Flow chart for the management of Delirium

APPENDIX II: MONTREAL COGNITIVE ASSESSMENT (MOCA)


APPENDIX III: ABBREVIATED MENTAL TEST SCORE (AMT)21. A score of less than 8/10 is abnormal

1. Age 2. Time (to nearest hour) 3. Address for recall at end of test (42 West St – need to recall all to gain point) 4. Year 5. Name of hospital/place 6. Recognition of 2 persons (eg doctor, nurse) 7. Date of Birth 8. Year of 1st World War 9. Name of present monarch

10. Count backwards 20-1 (this tests attention)


APPENDIX IV: – SOME OF THE DRUGS / GROUPS THAT MAY PRECIPITATE DELIRIUM (THIS LIST IS NOT EXHAUSTIVE)

• Benzodiazepines eg lorazepam• Analgesics such as codeine, tramadol and other opiates• Dopamine agonists eg ropinirole• Anticonvulsants eg carbamazepine• Antidepressants eg amitryptilline• Diuretics eg furosemide• Anti-arrhytmics eg digoxin• Corticosteroids eg prednisolone• Oxybutinin• Lithium• Methyldopa


APPENDIX V: DELIRIUM AUDIT TOOL To be completed on any patients that are admitted to hospital with a new diagnosis of confusion or increase confusion

Male Female Age1. What was the patient’s length of stay? (Number of

days)2. Where were they admitted from? Own Home

Rest homeNursing homeOther, please state

3. What was the discharge destination? Own homeRest HomeNursing homeOther, please state

4. Is there evidence of cognitive testing on admission Yes No5. Is an MMSE or AMT completed on admission Yes No6. Is pre admission state documented Yes No7. Is a cognitive test repeated during the patients stay Yes No8. Is there evidence of a physical examination Yes No9. Is there evidence of a clear history within 48 hrs This

should include considerations of the following factors:-

Yes No

Full drug historySensory impairmentsAlcohol historyBowel habitsDrug HistoryPrevious intellectual function (e.g. ability to manage household affairs)Functional status (e.g. actives of daily living)Onset and course of confusionPrevious episodes of acute or chronic confusionSymptoms suggestive of underlying cause (e.g. infection)

11. Is there adequate assessment of causes:- Yes NoFull blood count including C Reactive ProteinUrea and electrolytes, Calcium, blood culturesGlucoseChest X-rayECGPulse oximetryUrinalysisLiver function testsThyroid function tests

12. Has emergency IM sedation been used Yes No13 Is there a clear medical treatment plan Yes No14 Is there evidence of evaluation of this treatment plan Yes No15 Is there an absence of labelling words Yes NoGuidelines for the Diagnosis and Management of Older People with Delirium in a General Hospital settingVersion: 2. Issue Date: 20 February 2018Review Date: 19 February 2020 (unless requirements change) of 32

16 Is there evidence of psychological care planning Yes No17 Is there evidence of person centred care Yes No18 Is there evidence of discussion with family / friends

re patients condition19 Did the patient experience any non clinical ward

moves


APPENDIX VI: DELIRIUM INFORMATION FOR PATIENTS AND RELATIVES – Adapted from the Royal College of Psychiatrists36

About this leafletYou may find this leaflet useful if :-

You have experienced delirium You know someone with delirium You are looking after someone with delirium

What is delirium?Delirium is a state of mental confusion. It is also known as an ‘acute confusional state’. It often starts suddenly, but usually lifts when the condition causing it gets better. It can be frightening – not only for the person who is unwell, but also for those around him or her.

What is it like to have delirium?You may:-

Be less aware of what is going on around you Be unsure where you are or what you are doing there Be unable to follow a conversation or to speak clearly Have vivid dreams which are often frightening and may carry on when you wake up Hear noises or voices when there is nothing or no-one to cause them See people or things which aren’t there Worry that other people are trying to harm you Be very agitated or restless, unable to sit still and wandering about Be very slow or sleepy Sleep during the day but wake up at night Have moods that change quickly. You can be frightened, anxious, depressed or

irritable Be more confused at some times than at others, often in the evening or at night

How common is it? Up to one in three hospital patients have a period of delirium. Delirium is more common in people who:-

Are older Have memory problems, poor hearing or eyesight Have recently had surgery Have a terminal illness Have an illness of the brain such as an infection, a stroke or a head injury

Why does it happen?Many conditions and circumstances can cause or contribute to delirium

Being in an unfamiliar place Infections Having a high body temperature Constipation Side effects of drugs like pain killers or steroids Chemical problems in the body such as dehydration or low salt levels Liver or kidney problems Suddenly stopping drugs or alcohol Major surgery Brain injury (such as stroke), epilepsy


Terminal illnessThere is often more than one cause and sometimes the cause is not found.

How is delirium treated?If someone suddenly becomes confused, they need to see a doctor urgently. The person with delirium may be too confused to describe what has happened to them so it’s important that the doctor can talk to someone that knows the patient well. To treat delirium you need to treat the cause, for example an infection may be treated with antibiotics.

Can sedative medication (tranquilisers) help?Not everyone with delirium will need sedatives but they may be needed in the following situations:

To calm someone enough to have investigations or treatment To stop someone endangering themselves or other people When someone is very agitated, anxious or distressed as a result of delirium When someone who drinks a lot of alcohol stops suddenly they may need a regular

dose of a sedative medication that is reduced over several days. This will help with withdrawal symptoms but should be done under close medical supervision.

Sometimes sedatives may make delirium worse and this will be monitored by the medical and nursing team

How can I help someone with delirium?You can help someone with delirium feel more calmer and in control if you:-

Stay calm Talk to them in short simple sentences Check they have understood you. Repeat things if necessary Try not to agree with any unusual or incorrect ideas but tactfully disagree or change

the subject Reassure them Remind them of what is happening and how they are doing Remind them of the time and date Make sure that they can see a clock or calendar Try to make sure that someone they know well is with them. This is often important

during the evening when confusion often gets worse If they are in hospital bring in some familiar objects from home Make sure they have their glasses and hearing aids Help them to eat and drink Have a light on at night so that they can see where they are if they wake up

How long does it take to get better?Delirium gets better when the cause is treated. You can recover very quickly but it can take several days or weeks and some may not completely recover. People with dementia can take a particularly long time to get over delirium.

How do you feel afterwards?


You may not remember what has happened particularly if you have had memory problems beforehand. However you may be left with unpleasant and frightening memories and even worry that you are going mad. It can be helpful to sit down with someone who can explain what happened. This might be a family member, a carer or your doctor. They can go through a diary of what happened each day. Most people relieved when they understand what happened and why.

Will it happen again?You are more likely to have delirium again if you become medically unwell. Someone needs to keep an eye out for the warning signs that you are getting unwell again – whatever the original cause was. If they are worried they should get a doctor as soon as possible. If medical problems are treated early this can prevent delirium from happening again.

APPENDIX VII: – THE CONFUSION ASSESSMENT METHOD (CAM) 37


The diagnosis of delirium requires a present or abnormal rating for criteria 1 and 2 plus either 3 or 4. The patient should have a cognitive test such as AMTS or MoCA.

1. Acute onset and fluctuating course – is there evidence of an acute change in mental status from the patient’s baseline? Did this behaviour fluctuate during the past day – that is, tend to come and go or increase and decrease in severity? (Usually requires information from a family member or carers)

2. Inattention – does the patient have difficulty focusing attention – for example, are they easily distracted or do they have difficulty keeping track of what is being said? (Inattention can be detected by the digit span test or asking for the days of the week to be recited backwards)

3. Disorganised thinking – is the patient’s speech disorganised or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching between subjects? (Disorganised thinking and sleepiness can also be detected during conversation with the patient)

4. Altered level of consciousness – overall, would you rate this patient’s level of consciousness as alert (normal), vigilant (hyperalert), lethargic (drowsy, easily aroused), stupor (difficult to arouse), or coma (cannot be roused)? All ratings other than alert are scored as abnormal.


APPENDIX VIII: THE 4AT TEST

4ATAssessment testfor delirium & cognitive impairment

CIRCLE[1] ALERTNESSThis includes patients who may be markedly drowsy (eg. difficult to rouse and/or obviously sleepy during assessment) or agitated/hyperactive. Observe the patient. If asleep, attempt to wake with speech or gentle touch on shoulder. Ask the patient to state their name and address to assist rating.

Normal (fully alert, but not agitated, throughout assessment) 0Mild sleepiness for <10 seconds after waking, then normal 0Clearly abnormal 4

[2] AMT4Age, date of birth, place (name of the hospital or building), current year.

No mistakes 01 mistake 12 or more mistakes/untestable 2

[3] ATTENTIONAsk the patient: “Please tell me the months of the year in backwards order, starting at December.” To assist initial understanding one prompt of “what is the month before December?” is permitted.

Months of the year backwards Achieves 7 months or more correctly 0Starts but scores <7 months / refuses to start 1Untestable (cannot start because unwell, drowsy, inattentive) 2

[4] ACUTE CHANGE OR FLUCTUATING COURSEEvidence of significant change or fluctuation in: alertness, cognition, other mental function (eg. paranoia, hallucinations) arising over the last 2 weeks and still evident in last 24hrs

No 0Yes 4

4 or above: possible delirium +/- cognitive impairment1-3: possible cognitive impairment 0: delirium or severe cognitive impairment unlikely (but delirium still possible if [4] information incomplete)

4AT SCORE


(label)Patient name:

Date of birth:

Patient number:

___________________________________________________

Date: Time:

Tester:

GUIDANCE NOTES Version 1.2. Information and download: www.the4AT.comThe 4AT is a screening instrument designed for rapid initial assessment of delirium and cognitive impairment. A score of 4 or more suggests delirium but is not diagnostic: more detailed assessment of mental status may be required to reach a diagnosis. A score of 1-3 suggests cognitive impairment and more detailed cognitive testing and informant history-taking are required. A score of 0 does not definitively exclude delirium or cognitive impairment: more detailed testing may be required depending on the clinical context. Items 1-3 are rated solely on observation of the patient at the time of assessment. Item 4 requires information from one or more source(s), eg. your own knowledge of the patient, other staff who know the patient (eg. ward nurses), GP letter, case notes, carers. The tester should take account of communication difficulties (hearing impairment, dysphasia, lack of common language) when carrying out the test and interpreting the score. Alertness: Altered level of alertness is very likely to be delirium in general hospital settings. If the patient shows significant altered alertness during the bedside assessment, score 4 for this item. AMT4 (Abbreviated Mental Test - 4): This score can be extracted from items in the AMT10 if the latter is done immediately before. Acute Change or Fluctuating Course: Fluctuation can occur without delirium in some cases of dementia, but marked fluctuation usually indicates delirium. To help elicit any hallucinations and/or paranoid thoughts ask the patient questions such as, “Are you concerned about anything going on here?”; “Do you feel frightened by anything or anyone?”; “Have you been seeing or hearing anything unusual?”


APPENDIX IX: PLAN OF CARE FOR MANAGING A PATIENT WITH DELIRIUM

Name:DOB:NHS:

Behaviour that challenges – Plan of care Date:

- Please approach Mr/Mrs/Ms **** using a calm tone of voice with a clear/concise reason for interaction. It is preferable for one member of staff to speak as more than this could increase his/her confusion.

- If Mr/Mrs/Ms **** reacts to your interaction/intervention with irritability/aggression always respond in a calm manner and take a step back as appropriate, this can help prevent an escalation to the situation. Returning to complete tasks/interventions at a later time may be beneficial.

- Try not to show any fear, alarm or anxiety, as this may increase his agitation -although if you feel threatened, this is easier said than done. Risk assess the need for a specific number of staff for each intervention and call for help if indicated.

- Try not to raise your voice or initiate physical contact before an explanation of why you are there, this could be misinterpreted as threatening behaviour. If his/her behaviour becomes physically aggressive, give him/her plenty of space and time. Unless it is absolutely necessary, avoid closing in or trying to restrain someone, as this can make things worse.

- Reassure Mr/Mrs/Ms **** and acknowledge his/her feelings.- Listen to what s/he is saying. This demonstrates that you are not against him/her and that

you want to help.- Encourage communication.- Try to find out what is causing the behaviour.- Try to distract his/her attention if s/he presents as angry.- Ask yourself if whatever you are trying to do for him/her really needs to be done at that

moment. If you are able to give him/her space, come back later and try again - you may be able to avoid a confrontation.

- Always consider any other potential factors: Is s/he in pain? Is s/he getting enough stimulation? Is the environment suitable?

Please continue to monitor for triggers for behaviour that challenges:-Assess him/her in the situation. Is s/he: Unwell, in pain, uncomfortable? Overtired, overstimulated, bored, anxious or frustrated? Embarrassed, ignored, misunderstood, feeling patronised? Delusional, having hallucinations?

Name:DOB:NHS:Guidelines for the Diagnosis and Management of Older People with Delirium in a General Hospital settingVersion: 2. Issue Date: 20 February 2018Review Date: 19 February 2020 (unless requirements change) of 32

Is there a physical factor e.g. constipation/UTI? Under-stimulated, lacking in social contact? In a suitable environment?

Additional thoughts to promote a sense of calmCommunication – When communicating the content, pace and tone of the conversation/wording, as well as non-threatening body language, are all important in helping the person feel they are being respected and listened to.

Music - Listening to their favourite music may help to reduce aggressive/agitated behaviour. For example, if there is a certain time of day when s/he tends to become more unsettled/aggressive, it may help to put on some music that you know s/he may enjoy at that time.

Social interaction and stimulation – Ensuring on-going social interaction can also be beneficial. Simple types of interaction such as a chat or reading together can provide suitable stimulation. If a particular activity works then keep doing it.

Reminiscence - Reminiscence or talking about his past experiences is another source of beneficial activity. These should be positive and personally significant, the ‘This is me booklet’ can help facilitate these interactions. They have been found to improve the mood of people with dementia, reducing the risk of aggressive behaviour.

Changes to the environment - Think about his/her surroundings, as these will have an effect on his/her behaviour. It may be that you can make small changes to the environment that will make it a better environment for him. For example: Is there enough light? Is it too hot or too cold? Is it too noisy?

Further support can be obtained from:-Mental Health liaison Team (OPMH)Ext: 6670 / 4074Bleep: 0066

EQUALITY IMPACT SCREENING TOOLTo be completed and attached to any procedural document when submitted to the appropriate

committee for consideration and approval for service and policy changes/amendments.


Stage 1 - Screening

Title of Procedural Document: Delirium Guidelines for Older People

Date of Assessment 05 February 2018 Responsible Department

MOPRS CSC

Name of person completing assessment

J Carter Job Title Consultant

Does the policy/function affect one group less or more favourably than another on the basis of :

Yes/No Comments

Age No

Disability No

Gender reassignment No

Pregnancy and Maternity No

Race No

Sex No

Religion or Belief No

Sexual Orientation No

Marriage and Civil Partnership No

If the answer to all of the above questions is NO, the EIA is complete. If YES, a full impact assessment is required: go on to stage 2, page 2

More Information can be found be following the link below

www.legislation.gov.uk/ukpga/2010/15/contents

Stage 2 – Full Impact Assessment

What is the impact Level of Impact

Mitigating Actions(what needs to be done to

minimise / remove the impact)

Responsible Officer


http://www.legislation.gov.uk/ukpga/2010/15/contents

Monitoring of Actions

The monitoring of actions to mitigate any impact will be undertaken at the appropriate level

Specialty Procedural Document: Specialty Governance CommitteeClinical Service Centre Procedural Document: Clinical Service Centre Governance CommitteeCorporate Procedural Document: Relevant Corporate Committee

All actions will be further monitored as part of reporting schedule to the Equality and Diversity Committee
