Delirium Screening Audit

This project audits the quality, completeness and reliability of delirium screening and documentation. It reviews whether delirium risk factors, screening tool use, results, escalation, prevention and care planning and onward communication are documented clearly enough to support safe care, in line with NICE CG103 and QS63 and local policy.

• Acute medicine, emergency medicine and general internal medicine teams
• Frailty, geriatric medicine and orthogeriatric teams
• Nurses, pharmacists, ACPs and physician associates
• Care home clinical leads, community and hospice teams where locally relevant
• QI leads, governance teams and educators

• Measure documentation of delirium risk assessment and screening in eligible records
• Assess use and recording of the locally approved screening tool and its result
• Assess escalation, senior or MDT review where delirium is suspected or identified
• Identify variation by clinical area / location and optional specialty / service
• Generate governance-ready and ARCP-ready evidence

• Anonymous case identifier
• Inclusion / eligibility decision
• Anonymised biodata (age band, recorded sex/gender, care setting, delirium screening context)
• Clinical area / location and optional specialty / service
• Twenty delirium recognition, screening, assessment, management and communication criteria (met / not met / not applicable)
• Free-text learning points and any project custom fields

• Live dashboard
• Audit report (Word)
• Executive summary (Word)
• Excel workbook
• PowerPoint presentation
• Conference poster
• ARCP evidence summary

This ready-built project is developed using the guidance, standards and authoritative sources listed below, so you can see what is being measured and why. Lazomis QI does not publish or own this guidance, and inclusion here does not imply endorsement or approval by any of these organisations.

• NICE

  CG103: Delirium — prevention, diagnosis and management in hospital and long-term care(opens the original source in a new tab)

  Sets out expectations for identifying people at risk, assessing for indicators of delirium and documenting prevention and management.

• NICE

  QS63: Delirium in adults(opens the original source in a new tab)

  Quality statements covering risk assessment, timely assessment for delirium and communication of the diagnosis.

• NICE

  NG97: Dementia — assessment, management and support(opens the original source in a new tab)

  Relevant where delirium is superimposed on dementia or cognitive impairment, including collateral history and carer involvement.

• NICE

  NG5: Medicines optimisation(opens the original source in a new tab)

  Supports review of high-risk, anticholinergic and sedative medicines as contributing factors in delirium.

• 4AT (Scottish Delirium Association / academic collaboration)

  The 4AT rapid clinical test for delirium(opens the original source in a new tab)

  Widely used screening instrument; use only where adopted by local policy, and follow local scoring and escalation rules.

• Royal College of Physicians

  National Hip Fracture Database and delirium standards(opens the original source in a new tab)

  Context for delirium screening within orthogeriatric and hip fracture pathways.

• Designed to use anonymised or pseudonymised audit identifiers.
• This tool supports, but does not replace, clinical judgement.
• Local policy, formulary and specialist advice should be followed.
• Organisations remain responsible for local governance arrangements.
• This tool supports, but does not replace, clinical judgement. Follow local policy, formulary and specialist advice.
• Use anonymous case identifiers only — never patient-identifiable information.

Supporting guidance from the Lazomis QI Resource Library. Authoritative clinical standards referenced by this project remain separate.

• Clinical GovernanceLeveraging Incident Themes for Quality Improvement and Patient SafetyThis guide helps NHS teams identify and analyse recurring incident themes, transforming reported safety events into practical quality improvement opportunities to enhance patient safety and system reliability.
• Patient SafetyDiagnostic Delay: Understanding and Mitigating a Critical Patient Safety RiskDiagnostic delay is a significant patient safety concern across all healthcare settings. This guide explains why timely diagnosis is crucial, details the common factors contributing to delays, and provides actionable strategies for healthcare professionals and teams to mitigate these risks.
• Patient SafetyHow to Select a Patient Safety Quality Improvement ProjectThis guide helps NHS teams identify and select patient safety quality improvement (QI) projects that are impactful, achievable, and aligned with organisational and national priorities. Learn how to move from identifying concerns to choosing a focused and measurable project.
• Patient SafetyIntegrating Patient Safety and Quality Improvement: A Practical Guide for UK CliniciansThis guide explains the foundational principles of patient safety and quality improvement (QI) within the UK healthcare context, offering practical strategies for clinicians to enhance safety and improve care delivery.