Cognitive impairment and behavioural emergencies within the acute hospital setting

BACKGROUND: Patients with cognitive impairment exhibiting agitation and aggression are challenging to manage in the acute hospital setting. When a patient’s behaviours place themselves or others at risk of harm, a Clinical Aggression Response Team (C-ART) is dispatched. The aims of this project were to describe the characteristics of patients receiving a C-ART call and the experiences of C-ART staff members via semistructured interviews. Additionally, to audit local practice against two established standards of practice (Local C-ART Call Guideline and Australian Cognitive Impairment Guideline), to develop interventions to address identified shortfalls in adherence to these standards of practice and finally to re-evaluate adherence postintervention. METHODS: A retrospective pre and postintervention audit using qualitative (interview) and quantitative (file review) mixed method research approach was used. Interventions targeted doctor hospital orientation sessions, distribution of hospital guidelines including a new pharmacological sedation guideline and finally ward-based brief education sessions. RESULTS: Themes identified postintervention included improved familiarity with C-ART terminology, better understanding of C-ART member roles and improved communication among medical teams. However, there was continued pressure to use pharmacological sedation, a lack of debriefing and poor patient handover. File review of patients postintervention showed improvement from 36.8% to 65.6% in recording a provisional diagnosis and differentials for a patient behaviour necessitating a C-ART call. Additionally, the use of psychotropics during C-ART calls was lowered by 3.3% but did not reach significance (p=0.62). CONCLUSION: Behavioural disturbances in the elderly present many challenges for health staff. Interactive orientation sessions for doctors and distribution of hospital guidelines were shown to improve compliance with Local C-ART Call and Australian Cognitive Impairment Guidelines. Patients who receive multiple C-ART calls require further exploration and consideration, as this subset of the patient population present unique challenges.