Summary
Background Emergency departments (EDs) in the UK face extreme pressure, with patients waiting in ambulances or on trolleys due to a lack of available beds. The environment can be loud, lack natural light, and chaotic, making it particularly challenging for older adults. Delirium is a sudden, temporary state of confusion where a person may have trouble thinking clearly, staying focused, or recognising where they are, often caused by illness, infection, or medication changes. People with delirium might feel confused about their surroundings, see or hear things that aren t there, or become restless or sleepy. Delirium affects over 30% of older ED patients and can lead to increased risk of falls, nursing home placement and even death. Improving delirium care can improve patient safety, quality of life, and reduce ED pressures. Aim This project aims to understand how delirium impacts ED patients and gather data to inform a larger research funding application. Work Plan The project will take place across two hospitals, using an approach called systems engineering. This helps us looks at the big picture when solving problems.
Instead of focusing on just one part, it considers how all the different parts of a system—like people and technology—work together to create the best overall solution. This approach aims to improve systems rather than attributing errors to individuals.
Study 1- Engaging stakeholders: Running throughout, six workshops will engage people with lived experience of delirium and healthcare professionals. Participants will help us understand findings from Studies 1 and 2, prioritise outcomes, and work with us to design and write our programme grant.
Study 2- Understanding ED Systems: We will explore how care is delivered in EDs by holding focus groups and interviews with staff, patients, and family carers. We will identify key roles, resources, and procedures in delirium care, as well as barriers and enablers to safe care delivery.
Study 3- Mapping Patient Journeys: We will track older patients with delirium through the ED to identify critical care points and potential outcomes, such as fall prevention or reduced stays. A three-hour in-person focus group with staff and meetings with patient and public representatives will produce “Journey Maps” showing typical patient experiences. Patient and Public Involvement (PPIE) PPIE is central to this proposal. A group, led by Ward, will meet quarterly to support research outputs, sharing results, and engagement. The bid was developed with Ward and local community organisations, including older adults with lived experience of dementia and family carers. Sharing the results and Impact Findings will be shared through publications, conferences, public events, stakeholder workshops, social media, blogs, and a policy brief. This will increase awareness of the need to improve delirium care in EDs, enhancing services and outcomes for older adults.
Abstract
BACKGROUND UK emergency departments (EDs) face significant challenges with overcrowding and patient flow and are risky environments for older adults. Delirium, triggered by stressors such as infections or sleep-deprivation, is a clinical emergency affecting over 30% of older ED patients, causing acute changes in cognition, alertness and behaviour. This leads to poor outcomes, patient safety incidents (i.e. falls) and increased mortality. Optimising delirium care would improve outcomes, safety, and ED pressures. AIM Using a human-centred, systems-engineering approach, to understand how delirium contributes to poor patient outcomes in the ED, we will collect data required to develop a Programme Grant for Applied Research (PGfAR). Objectives Set-up expert stakeholder group For older adults with delirium in the ED: Map resources required to deliver safe care. Understand care pathway, barriers and facilitators for patient safety. Conduct preparatory work to: Identify pragmatic and feasible interventions and outcomes Draft an initial logic model and PGfAR application DEVELOPMENT WORK PLAN Work is delivered via three work packages (WP) conducted in EDs at two acute hospitals ensuring diverse stakeholders and generalisability. Errors and problems in healthcare are often not due to individual actions, but the system and processes people work with. The Systems Engineering Initiative for Patient Safety (SEIPS) Model underpins project structure, data collection and analyses.
WP1: Integrated Stakeholder Co-Production Focusses on engagement with people with lived experience and clinical stakeholders. Through six workshops they will synthesise data from WPs and co-design the PGfAR, prioritising outcomes and measurement metrics, creating an initial logic model and drafting the application.
WP 2: Understanding ED Environments and Systems of Working Focusses on structures of care delivery in EDs. Using semi-structured interviews and focus groups we will explore staff roles, patient experiences, tools, tasks and systems in place for care provision. Interviews and focus groups will be transcribed and analysed (thematic analysis), informed by SEIPS model. We will produce tables of facilitators and barriers to delirium care, tasks and tools used and map the care staff involved.
WP3: Understanding Processes and Outcomes for People with Delirium in the ED Focusses on mapping journeys of people with delirium, identifying transition points, and understanding outcomes- both desirable (e.g., avoiding falls) and undesirable (e.g., prolonged ED stays). With PPIE members we will create archetypal patient pathways “Journey Maps” including their experiences. DELIVERY TIMELINES Prior to start: apply for ethical and governance permissions Months 1-3: appoint research assistant, form stakeholder group, workshop 1 (WP1), receive ethical approval Months 2- 10: Recruit and interview participants (WP2), focus groups with professionals (WP2), workshop 2 (WP1) Months 10-15: Process mapping focus groups (WP3), nominal group (WP1), logic model development workshop 4 (WP1) Months 15-18: Workshops 5-6 to develop PGfAR application (WP1) ANTICIPATED IMPACT AND DISSEMINATION We include broad dissemination across platforms, engaging professionals, public and policy makers, including: peer-reviewed publications, conference presentations, local public engagement events, social media, Blogs, and a policy brief demonstrating the importance of good delirium care in the ED to improve services and patient safety.
