The bedside guide
Use ACE-T
Start after a positive delirium screen or recognition of suspected delirium. Consider each domain and complete, initiate or escalate the actions that apply.
Complete, initiate or escalate the applicable ACE-T actions within four hours of a positive delirium screen.
Act immediately on urgent concerns. Actions can happen in parallel; the four-hour target is not a reason to wait.
Use clinical judgement and local pathways. ACE-T does not require nurses to diagnose the underlying cause or arrange investigations outside their role.
Acute triggers
Look for problems that need assessment or action.
- Check observations. Pulse, blood pressure, oxygen saturation, respiratory rate, temperature and conscious level.
- Check capillary blood glucose.
- Check whether routine blood tests have been sent. Follow local policy for investigations and escalation.
- Assess for urinary retention and constipation.
- Assess hydration and nutrition.
- Initiate or review an infection work-up where appropriate. Use clinical findings and local guidance.
- Assess pain. Record whether it is absent, mild, moderate or severe.
- Check that a medication review has been completed.
Patient experience
Attend to the person as well as the clinical findings.
- Assess distress. Observe the person and ask how they are feeling. Consider the Quick Distress Assessment Tool (QDAT), where appropriate.
- Note agitation.
- Reassure and reorient. Explain where the person is, what is happening and who you are.
- Consider the care environment. For example, whether a single room would be appropriate.
- Make sensory and communication aids available. Check glasses, hearing aids and other communication aids.
- Consider involving relatives, friends or carers.
Treatment & communication
Provide support and make the next steps clear.
- Assess falls risk.
- Provide immediate support if needed. Fluids, oxygen and other support as appropriate, within local policy and your scope of practice.
- Document 4AT score and delirium. Use “delirium” or “? delirium” as appropriate. Where another local delirium assessment tool is used, record its score.
- Communicate the delirium plan. Share the screening score and relevant findings with the clinical team.
- Discuss actions with the team. Agree the treatment plan with the multidisciplinary team, including what needs to happen next.
- Inform the family where appropriate. Offer delirium information to the patient and family, including a leaflet where appropriate.
Continue the care
ACE-T provides an initial response. Revisit relevant actions as the person’s condition changes, and continue the wider delirium treatment plan. Hand over the delirium, the assessment score, actions taken and outstanding concerns.
Adapted from Table 1 of the current ACE-T development and pilot manuscript. This web guide uses 4AT wording; the manuscript also accommodates local delirium screening tools. Read about the source and evidence.