Objectives To identify clinical checklists of multicomponent non-pharmacological interventions for the prevention and treatment of delirium used in non-intensive care unit inpatient healthcare settings, their content and reported implementation.Design Rapid review.Data sources Medline, Embase, PsycINFO, CINAHL and Cochrane CENTRAL were searched from 1 January 1999 to 31 March 2022 and updated on 16 January 2025. A comprehensive grey literature search, including websites of guideline development groups and international delirium organisations, was conducted on 26 and 27 February 2024.Eligibility criteria We included records reporting the use of a ‘clinical checklist’ used by the healthcare team, family carers or adult patient (≥18 years) to prompt and document multicomponent non-pharmacological interventions for the prevention or treatment of delirium. Publication language was restricted to English and French.Data extraction and synthesis Using rapid review methodology, two independent reviewers screened the included records. A single reviewer undertook the data extraction, with a third independent reviewer verifying the data extraction for completeness. All included studies were assessed using the JBI critical appraisal tools according to the study design. A narrative synthesis was used to summarise the findings.Results From the database searches, 4796 records were identified. After the removal of duplicates, 3513 records underwent title and abstract screening, with 344 records undergoing full-text screening. A final 32 records were included. From the grey literature search, 6593 records were reviewed for relevance, from which 62 records were included in full-text screening. No grey literature records were of high enough quality to be included. All studies were published in English, with most studies conducted in the USA, n=12/32 (37.5%). The 32 studies were quasi-experimental (n=18), randomised controlled trials (n=8), qualitative (n=4), expert opinion (n=1) and policy/consensus guidelines (n=1). Clinical checklists included structured protocols, algorithms and order sets, which were paper-based or part of electronic delirium order sets. People with dementia participated as key stakeholders for a guidance document during the COVID-19 pandemic, but the target population was not included in the development phase of other checklists. Target users of clinical checklists were usually healthcare staff and trained volunteers and rarely family carers and study intervention nurses. Four of the 32 studies included all 10 National Institute for Health and Care Excellence clinical factors/preventive strategies for non-pharmacological interventions. For the remaining 28 studies, missing domains varied and included: therapeutic/cognitive activity, hydration, nutrition, constipation, urinary catheterisation, hypoxia, infection, pain and medication review. Only two studies involved family carers as active partners in patient care. Reported formal economic analysis was limited.Conclusions Codesign of future clinical checklists should involve patients and family carers. Further research is needed on the feasibility of using clinical checklists by all members of the interprofessional team and family carers, the factors needed to ensure high levels of adherence and sustainability of multicomponent non-pharmacological interventions for delirium management, in addition to economic evaluations.PROSPERO registration CRD42022342328.

Abstract Background Type 2 Diabetes prevalence is rapidly increasing in low- and middle-income countries (LMICs), where constrained health budgets and inequitable resource distribution limit access to quality care. Primary healthcare is central to addressing these challenges; however, the implementation of evidence-based diabetes care remains inconsistent. This scoping review mapped implementation strategies for integrating diabetes care into primary healthcare settings in LMICs and identified associated barriers and facilitators influencing implementation. Methods This review focuses on type 2 diabetes, given its predominance and relevance to primary healthcare delivery in LMICs, and followed the Joanna Briggs Institute methodology for scoping reviews and was reported in accordance with PRISMA-ScR guidelines. The search strategy was peer-reviewed using the PRESS checklist. Eight electronic databases were searched for studies published between January 1996 and November 2024. Eligible studies were conducted in LMICs, as defined by the World Bank, and described the implementation, adaptation, or evaluation of evidence-based Type 2 diabetes care in primary healthcare settings. Two reviewers independently screened titles, abstracts, and full texts. Implementation strategies were mapped to the Expert Recommendations for Implementing Change (ERIC) taxonomy, while reported barriers and facilitators were coded using the Consolidated Framework for Implementation Research (CFIR). Results Ninety-two articles describing 85 studies across 27 LMICs were included. Implementation strategies most frequently clustered within Engage Consumers , Change Infrastructure , and Use Evaluative and Iterative Strategies , whereas Adapt and Tailor to Context and Utilise Financial Strategies were less often explicitly reported. Forty-three studies reported clinical outcomes only, 11 reported implementation outcomes only, and 31 reported both. Studies more frequently reported improvements in clinical and/or implementation outcomes that combined multiple strategies, particularly provider training and decision support alongside patient or family engagement and pragmatic system redesign. Co-occurrence analyses indicated that Train and Educate Stakeholders was frequently paired with Engage Consumers , supported by supervision, feedback mechanisms, and infrastructure strengthening. CFIR mapping suggested that workflow integration, leadership engagement, regular supervision, and reliable medicine and diagnostic supplies were commonly associated with improved adoption and fidelity, while connectivity challenges, stock-outs, and high workload disrupted implementation and limited scale-up. Reporting of adoption, fidelity, and acceptability remained uneven, and financial strategies were poorly described despite their relevance to sustainability. Conclusion In LMIC primary healthcare settings, diabetes care implementation most commonly emphasises provider training, infrastructure strengthening, and interactive support strategies, while explicit attention to contextual adaptation and financial mechanisms is less frequently reported. Implementation outcomes were reported to be influenced by leadership engagement, digital tools, and community involvement, alongside persistent constraints related to workforce capacity, supply chains, and feedback systems. Future implementation efforts should more explicitly address contextual fit, system integration, and sustainability when designing and scaling diabetes care interventions in primary healthcare.

Background: Delirium is common and distressing for hospice in-patients. Hospital-based research shows delirium may be prevented by targeting its risk factors. Many preventative strategies address patients’ fundamental care needs. However, there is little research regarding how interventions need to be tailored to the in-patient hospice setting. Aim: To explore the behaviours of hospice in-patient staff in relation to delirium prevention, and the influences that shape these behaviours. Design: Focused ethnography supported by behaviour change theory. Observation, semi-structured interviews and document review were conducted. Setting/participants: A total of 89 participants (multidisciplinary staff, volunteers, patients and relatives) at two UK in-patient hospice units. Results: Hospice clinicians engaged in many behaviours associated with prevention of delirium as part of person-centred fundamental care, without delirium prevention as an explicit aim. Carrying out essential care tasks was highly valued and supported by adequate staffing levels, multidisciplinary team engagement and role clarity. Patients’ reduced physical capability limited some delirium prevention behaviours, as did clinicians’ behavioural norms related to prioritising patient comfort. Delirium prevention was not embedded into routine assessment and care decision-making, despite its potential to reduce patient distress. Conclusions: The value placed on fundamental care in hospices supports delirium prevention behaviours but these require adaptation as patients become closer to death. There is a need to increase clinicians’ understanding of the potential for delirium prevention to reduce patient distress during illness progression; to support inclusion of delirium prevention in making decisions about care; and to embed routine review of delirium risk factors in practice.

People with severe mental illness (SMI) are at greater risk of obesity, cardiovascular disease and diabetes than the general population, due to a higher prevalence of health risk behaviours. Research is needed to inform tailored interventions to improve the health behaviours (diet, physical activity and sleep) of people with SMI in South Asia as these behaviours are closely linked to obesity. The study aimed to explore the barriers and facilitators to healthy diet, physical activity and good sleep among individuals with SMI. A qualitative design was employed using photovoice, semi-structured interviews and focus group discussions. Participants included 16 people with SMI, 16 caregivers and 17 health professionals in Bangladesh and Pakistan. Data were analysed thematically, informed by the socio-ecological framework. A complex interplay of individual, familial and societal factors influenced these health behaviours. Individual factors include knowledge, beliefs and mental health limitations. Caregivers play a crucial role in influencing behaviour. At the societal level, gender expectations, financial constraints and religious influences significantly impact these behaviours. The insights from this research can inform tailored interventions for this vulnerable group and highlight the need for integrated services, financial support and improved urban planning.

INTRODUCTION:Delirium is a complex condition in which altered mental state and cognition causes severe distress and poor clinical outcomes for patients and families, anxiety and stress for the health professionals and support staff providing care, and higher care costs. Hospice patients are at high risk of developing delirium, but there is significant variation in care delivery. The primary objective of this study is to demonstrate the feasibility of an implementation strategy (designed to help deliver good practice delirium guidelines), participant recruitment and data collection. METHODS AND ANALYSIS:Three work packages in three hospices in the UK with public involvement in codesign, study management and stakeholder groups: (1) experience-based codesign to adapt an existing theoretically-informed implementation strategy (Creating Learning Environments for Compassionate Care (CLECC)) to implement delirium guidelines in hospices; (2) feasibility study to explore ability to collect demographic, diagnostic and delirium management data from clinical records (n=300), explanatory process data (number of staff engaged in CLECC activities and reasons for non-engagement) and cost data (staff and volunteer hours and pay-grades engaged in implementation activities) and (3) realist process evaluation to assess the acceptability and flexibility of the implementation strategy (preimplementation and postimplementation surveys with hospice staff and management, n=30 at each time point; interviews with hospice staff and management, n=15). Descriptive statistics, rapid thematic analysis and a realist logic of analysis will be used be used to analyse quantitative and qualitative data, as appropriate. ETHICS AND DISSEMINATION:Ethical approval obtained: Hull York Medical School Ethics Committee (Ref 21/23), Health Research Authority Research Ethics Committee Wales REC7 (Ref 21/WA/0180) and Health Research Authority Confidentiality Advisory Group (Ref 21/CAG/0071). Written informed consent will be obtained from interview participants. A results paper will be submitted to an open access peer-reviewed journal and a lay summary shared with study site staff and stakeholders. TRIAL REGISTRATION NUMBER:ISRCTN55416525.

Introduction Delirium is a serious acute neurocognitive condition that is common in palliative care units and yet under-addressed. To improve delirium care in this setting, we will develop and pilot a monitoring system that integrates the Delirium Clinical Care Standard, Palliative Care Outcomes Collaboration (PCOC) methods, and perspectives of patients, carers and staff. Methods This paper reports the protocol for a two-stage, exploratory, sequential mixed-methods implementation study. Stage 1 data collection includes Delirium Standard-aligned process mapping and clinical audits, and Critical Incident Technique interviews with patients, carers and staff with a recent experience of delirium. We will present integrated stage 1 findings to stakeholders then collaboratively develop a delirium monitoring system that aligns with the Delirium Standard and PCOC methods. In stage 2, we will pilot the new system and repeat stage 1 data collection and analyses, adding PCOC and adverse event measures. Implementation principles and strategies such as audit and feedback and education will be applied. We developed simplified participants information sheets and consent forms for interview and process mapping participants, who will provide written informed consent; and waiver of consent to collect clinical audit, PCOC and adverse event data from patients’ medical records is approved. At study end, we will report implementation, effectiveness and safety outcomes, including systemic utility of the delirium monitoring system for wider testing and use to meet the Delirium Standard in palliative care units. Quantitative data analyses will include descriptive and inferential statistics and qualitative analyses will incorporate thematic content analysis aligned to the Critical Incident Technique. Mixed methods data integration will be at the end of each stage. Discussion This protocol paper describes the mixed methods, systems integration, and innovative measures and study processes of the MODEL-PC study. We also share data collection tools and a simplified information sheet and consent form for patients.

Background: Delirium is a complex condition, stressful for all involved. Although highly prevalent in palliative care settings, it remains underdiagnosed and associated with poor outcomes. Guideline-adherent delirium care may improve its detection, assessment and management. Aim: To inform a future definitive study that tests whether an implementation strategy designed to improve guideline-adherent delirium care in palliative care settings improves patient outcomes (reduced proportion of in-patient days with delirium). Design: With Patient Involvement members, we conducted a feasibility study to assess the acceptability of and engagement with the implementation strategy by hospice staff (intervention), and whether clinical record data collection of process (e.g. guideline-adherent delirium care) and clinical outcomes (evidence of delirium using a validated chart-based instrument;) pre- and 12-weeks post-implementation of the intervention would be possible. Setting/participants: In-patient admissions in three English hospices. Results: Between June 2021 and December 2022, clinical record data were extracted from 300 consecutive admissions. Despite data collection during COVID-19, target clinical record data collection ( n = 300) was achieved. Approximately two-thirds of patients had a delirium episode during in-patient stay at both timepoints. A 6% absolute reduction in proportion of delirium days in those with a delirium episode was observed. Post-implementation improvements in guideline-adherent metrics include: clinical delirium diagnosis 15%–28%; delirium risk assessment 0%–16%; screening on admission 7%–35%. Conclusions: Collection of data on delirium outcomes and guideline-adherence from clinical records is feasible. The signal of patient benefit supports formal evaluation in a large-scale study. Keywords Delirium , feasibility , guideline adherence , hospices , implementation

BACKGROUND:Delirium is a distressing condition often experienced by hospice in-patients. Increased understanding of current multidisciplinary care of delirium is needed to develop interventions in this setting. AIM(S):To explore hospice staff and volunteers' practice, its influences and what may need to change to improve hospice delirium care. DESIGN:Qualitative interview study using behaviour change theory from a critical realist stance. SETTING/PARTICIPANTS:Thirty-seven staff, including different professional groups and roles, and volunteers were purposively sampled from two in-patient hospices. RESULTS:We found that participants' practice focus was on managing hyperactive symptoms of delirium, through medication use and non-pharmacological strategies. Delirium prevention, early recognition and hypoactive delirium received less attention. Our theoretically-informed analysis identified this focus was influenced by staff and volunteers' emotional responses to the distress associated with hyperactive symptoms of delirium as well as understanding of delirium prevention, recognition and care, which varied between staff groups. Non-pharmacological delirium management was supported by adequate staffing levels, supportive team working and a culture of person-centred and family-centred care, although behaviours that disrupted the calm hospice environment challenged this. CONCLUSIONS:Our findings can inform hospice-tailored behaviour change interventions that develop a shared team understanding and engage staff's emotional responses to improve delirium care. Reflective learning opportunities are needed that increase understanding of the potential to reduce patient distress through prevention and early recognition of delirium, as well as person-centred management. Organisational support for adequate, flexible staffing levels and supportive team working is required to support person-centred delirium care.

Background Delirium is a complex condition, distressing for patients, family members and staff, and associated with poor outcomes. Despite high prevalence in the palliative care setting, it remains under-diagnosed. Delirium guideline-adherent care may both prevent and alleviate delirium. The best way to improve delirium-guideline adherence, and whether better adherence is reflected in reduced delirium, is not known. Prompt dissemination of feasibility findings is critical to avoid research waste. Methods To inform a definitive large study, working closely with Patient Public Involvement members, we conducted a co-design and feasibility study (ISRCTN55416525) to assess the feasibility of collecting data (delirium diagnosis; guideline-adherence) from clinical records. Clinical record data (evidence of: delirium using a validated chart-based instrument; guideline-adherent delirium care) was collected from 50 consecutive in-patient admissions at three hospices pre- and post-implementation of a co-designed implementation strategy (data collection completed 3 December 2022). Analysis: Pre-post comparison of percentages for continuous data (delirium outcomes); nominal data (raw count of guideline-adherent metrics). Results Target clinical record data collection (n=300) was achieved within timeframe, despite data collection during COVID-19. Delirium prevalence was comparable pre-and post-implementation with two-thirds of patients having a delirium episode during admission. There was a reduction in the proportion of delirium-days during admission 62% to 49%. We observed modest post-implementation improvements in most guideline-adherent metrics: delirium diagnosis as documented by the clinical team 15% to 26%; evidence of reversibility 33% to 36%; delirium risk assessment 0% to 12.5%; screening on admission 21% to 35%. Conclusion Data collection about delirium outcomes and guideline-adherence from hospice clinical records is feasible. Our findings show the disparity between need (high delirium-incidence) and documented action (low guideline-adherence). However, there is a signal of patient benefit even with small documented improvements which needs to be formally evaluated in a multi-site study of effectiveness of an implementation strategy for improving delirium guideline-adherence.

Background Delirium causes severe distress for patients, families, and staff. One-third of people admitted to adult palliative care units have delirium and two-thirds develop delirium during their stay (Watt, Momoli, Ansari, et al., 2019. Palliat Med. 33: 865), yet implementation of clinical guidelines is poor and assessment tools are used infrequently (Boland, Kabir, Bush, et al., 2022. BMJ Support Palliat Care. 12: 73). Strategies are needed to address this gap between knowledge and action (Featherstone, Hosie, Siddiqi, et al., 2021. Palliat Med. 35: 988). Aim To adapt the Creating Learning Environments for Compassionate Care (CLECC) strategy from acute settings for use in hospice delirium care. Methods We conducted three 2-hour Experience-Based Co-Design online workshops (Locock, Robert, Boaz, et al., 2014. Health Serv Deliv Res. 2) co-Chaired by a Patient & Public Involvement member. Participants had lived experience of delirium (personally or as a carer) or were hospice clinicians, domestic staff, or management. Workshops used examples of key delirium events to trigger discussion between patients/carers (Workshop 1), staff (Workshop 2), and patients/carers and staff (Workshop 3). Workshops 1 and 2 focused on adaptations to CLECC components (team study day, action learning sets, peer practice observations, mid-shift 'cluster discussions' and twice-weekly reflective discussions), whilst Workshop 3 focused on refining CLECC based on initial testing. The final specification of CLECC ('CLECC-Pal') for hospices at Workshop 4 will be informed by Process Evaluation findings. Results The workshops conducted to date prompted changes to CLECC delivery and content to address equity and implementation concerns and to reflect the different circumstances of hospices. Changes included: flexible access to study materials, recognition of staff working relationships, including all staff in reflective discussions, having core and adaptable CLECC components, and identification of hospice leads for each CLECC component. Conclusions Online Experience-Based Co-Design is a practical and feasible way of involving patients, carers, staff and management in adapting an existing intervention for hospice use. Our ongoing work is assessing signal of benefit of CLECC-Pal on number of patient delirium days. For more on this study, see also oral presentation (O-13): Improving the Detection, Assessment, Management and Prevention of Delirium in Hospices: The DAMPen-Delirium feasibility study, by Gillian Jackson et al. (Parallel session 4.1 – Patient care perspectives).

BACKGROUND:Delirium is common and distressing for patients receiving palliative care. Interventions targetting modifiable risk factors in other settings have been shown to prevent delirium. Research on delirium risk factors in palliative care can inform context-specific risk-reduction interventions.AIM:To investigate risk factors for the development of delirium in adult patients receiving specialist palliative care.DESIGN:Systematic review and meta-analysis (PROSPERO CRD42019157168).DATA SOURCES:CINAHL, Cochrane Database of Systematic Reviews, Embase, MEDLINE and PsycINFO (1980-2021) were searched for studies reporting the association of risk factors with delirium incidence/prevalence for patients receiving specialist palliative care. Study risk of bias and certainty of evidence for each risk factor were assessed.RESULTS:Of 28 included studies, 16 conducted only univariate analysis, 12 conducted multivariate analysis. The evidence for delirium risk factors was limited with low to very low certainty.POTENTIALLY MODIFIABLE RISK FACTORS:Opioids and lower performance status were positively associated with delirium, with some evidence also for dehydration, hypoxaemia, sleep disturbance, liver dysfunction and infection. Mixed, or very limited, evidence was found for some factors targetted in multicomponent prevention interventions: sensory impairments, mobility, catheter use, polypharmacy (single study), pain, constipation, nutrition (mixed evidence).NON-MODIFIABLE RISK FACTORS:Older age, male sex, primary brain cancer or brain metastases and lung cancer were positively associated with delirium.CONCLUSIONS:Findings may usefully inform interventions to reduce delirium risk but more high quality prospective cohort studies are required to enable greater certainty about associations of different risk factors with delirium during specialist palliative care.

Background Delirium causes severe distress for patients, families, and staff. One-third of people admitted to adult palliative care units have delirium and two-thirds develop delirium during their stay (Watt, Momoli, Ansari, et al., 2019. Palliat Med. 33:865), yet implementation of clinical guidelines is poor (NICE. Delirium: prevention, diagnosis and management - Clinical Guideline 103, 2010). Strategies are needed to address the gap between knowledge and action (Featherstone, Hosie, Siddiqi, et al., 2021. Palliat Med. 35: 988). Aim To assess the feasibility of timely and reliable clinical record data collection in hospices with different socio-economic profiles and record-keeping methods. Methods Phase one of the ongoing feasibility study collects clinical record data (demographic; evidence of delirium; [Inouye, Leo-Summers, Zhang, et al., 2005. J Am Geriatr Soc. 53: 312] guideline-adherent delirium care) from 50 consecutive in-patient admissions at four hospices. Data collection will be repeated following implementation of the co-designed Creating Learning Environments for Compassionate Care-Palliative (CLECC-Pal) intervention to support delirium guideline-adherence. The variation around baseline number of patient days with delirium will be calculated to inform the sample size needed for a future multi-site effectiveness study. Results To date, 100 clinical records have been reviewed from two hospices. In-patient characteristics differ considerably in age (mean 89 vs. 70 years), deprivation quintile (80% vs. 38% in least-deprived) and diagnosis (90% vs. 72% cancer). Overall, two-thirds of patients had a delirium episode during admission, for whom >75% of their in-patient days were delirium days. A delirium diagnosis was documented by the clinical team in <10% of cases. Guideline-adherent delirium risk assessment and screening was not documented in clinical records. Conclusion Our ongoing study is demonstrating: i) the feasibility of systematically and reliably collecting clinical record data about delirium occurrence and management; ii) the gap between need for delirium care and action (low guideline-adherence). Our emerging findings demonstrate the imperative for, and feasibility of, conducting a multi-site effectiveness study of the CLECC-Pal strategy for improving guideline-adherence in delirium care. For more on this study, see also Poster P-104: Improving the Detection, Assessment, Management and Prevention of Delirium in Hospices: The DAMPen-Delirium co-design process, by Mark Pearson et al.

Background: Trials of interventions for delirium in various patient populations report disparate outcomes and measures but little is known about those used in palliative care trials. A core outcome set promotes consistency of outcome selection and measurement. Aim: To inform core outcome set development by examining outcomes, their definitions, measures and time-points in published palliative care studies of delirium prevention or treatment delirium interventions. Design: Prospectively registered systematic review adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Data sources: We searched six electronic databases (1980–November 2020) for original studies, three for relevant reviews and the International Clinical Trials Registry Platform for unpublished studies and ongoing trials. We included randomised, quasi-randomised and non-randomised intervention studies of pharmacological and non-pharmacological delirium prevention and/or treatment interventions. Results: From 13/3244 studies (2863 adult participants), we identified 9 delirium-specific and 13 non-delirium specific outcome domains within eight Core Outcome Measures in Effectiveness Trials (COMET) taxonomy categories. There were multiple and varied outcomes and time points in each domain. The commonest delirium specific outcome was delirium severity ( n = 7), commonly using the Memorial Delirium Assessment Scale (6/8 studies, 75%). Four studies reported delirium incidence. Non-delirium specific outcomes included mortality, agitation, adverse events, other symptoms and quality of life. Conclusion: The review identified few delirium interventions with heterogeneity in outcomes, their definition and measurement, highlighting the need for a uniform approach. Findings will inform the next stage to develop consensus for a core outcome set to inform delirium interventional palliative care research.

Background: Delirium is common in palliative care settings and is distressing for patients, their families and clinicians. To develop effective interventions, we need first to understand current delirium care in this setting. Aim: To understand patient, family, clinicians’ and volunteers’ experience of delirium and its care in palliative care contexts. Design: Qualitative systematic review and thematic synthesis (PROSPERO 2018 CRD42018102417). Data sources: The following databases were searched: CINAHL, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Embase, MEDLINE and PsycINFO (2000–2020) for qualitative studies exploring experiences of delirium or its care in specialist palliative care services. Study selection and quality appraisal were independently conducted by two reviewers. Results: A total of 21 papers describing 16 studies were included. In quality appraisal, trustworthiness (rigour of methods used) was assessed as high ( n = 5), medium ( n = 8) or low ( n = 3). Three major themes were identified: interpretations of delirium and their influence on care; clinicians’ responses to the suffering of patients with delirium and the roles of the family in delirium care. Nursing staff and other clinicians had limited understanding of delirium as a medical condition with potentially modifiable causes. Practice focused on alleviating patient suffering through person-centred approaches, which could be challenging with delirious patients, and medication use. Treatment decisions were also influenced by the distress of family and clinicians and resource limitations. Family played vital roles in delirium care. Conclusions: Increased understanding of non-pharmacological approaches to delirium prevention and management, as well as support for clinicians and families, are important to enable patients’ multi-dimensional needs to be met.

OBJECTIVES:Delirium is common and distressing in palliative care settings. This survey aims to describe current practice regarding delirium identification in specialist palliative care units (SPCU), such as inpatient hospices, in the UK.METHODS:An 18-item anonymous online survey was distributed by Hospice UK to their network of clinical leads (n=223), and to their research mailing list (n=228). The survey was also sent to the chair of the Hospice UK executive clinical leads forum for direct dissemination to forum representatives (n=20). Clinical leads and forum representatives were asked to distribute the survey to healthcare staff in their SPCUs.RESULTS:220 SPCU staff (48% nurses; 31% doctors; 10% healthcare assistants) completed the survey. Approximately half reported using clinical judgement alone to screen (97/204; 48%) and/or diagnose (124/220; 56%) delirium. Over a third used an assessment tool to screen for delirium (76/204; 37%). The majority (150/220; 68%) reported screening in response to clinical symptoms, while few reported routine on-admission (11/220; 5%) or daily-during-admission (12/220; 6%) screening. Most respondents had received some training on delirium (137/220; 62%). However, 130/220 (59%) said their SPCU did not have a training programme for delirium screening and only 79/220 (36%) reported that their SPCU had delirium clinical guidelines. The main barriers to routine screening included: lack of delirium training, lack of guidelines and complexity of patient's conditions.CONCLUSION:There is variation in practice for delirium screening and diagnosis in SPCUs. Clinical guidelines for delirium, including consensus on which screening tools to use, are needed for this setting.

Objectives Delirium is common and distressing in palliative care settings. This survey aims to describe current practice regarding delirium identification in specialist palliative care units (SPCUs), such as inpatient hospices, in the UK. Methods An 18-item anonymous online survey was distributed by Hospice UK to their network of clinical leads (n=223), and to their research mailing list (n=228). The survey was also sent to the chair of the Hospice UK executive clinical leads forum for direct dissemination to forum representatives (n=20). Clinical leads and forum representatives were asked to distribute the survey to healthcare staff in their SPCUs. Results 220 SPCU staff (48% nurses; 31% doctors; 10% healthcare assistants) completed the survey. Approximately half reported using clinical judgement alone to screen (97/204; 48%) and/or diagnose (124/220;56%) delirium. Over a third used an assessment tool to screen for delirium (78/204;38%). The majority (150/220;68%) reported screening in response to clinical symptoms, while few reported routine on-admission (11/220;5%) or daily-during admission (12/220;6%) screening. Most respondents had received some training on delirium (137/220; 62%). However, 130/220 (59%) said their SPCU did not have a training program for delirium screening and only 79/220 (36%) reported that their SPCU had delirium clinical guidelines. The main barriers to routine screening included: lack of delirium training, lack of guidelines and complexity of patient’s conditions. Conclusion There is variation in practice for delirium screening and diagnosis in SPCUs. Clinical guidelines for delirium, including consensus on which screening tools to use, are needed for this setting.

Background: Delirium is common, distressing, serious and under-researched in specialist palliative care settings. Objectives: To examine whether people requiring palliative care were included in non-pharmacological delirium intervention studies in inpatient settings, how they were characterised and what their outcomes were. Design: Systematic review (PROSPERO 2017 CRD42017062178). Data sources: Systematic search in March 2017 for non-pharmacological delirium intervention studies in adult inpatients. Database search terms were ‘delirium’, ‘hospitalisation’, ‘inpatient’, ‘palliative care’, ‘hospice’, ‘critical care’ and ‘geriatrics’. Scottish Intercollegiate Guidelines Network methodological checklists guided risk of bias assessment. Results: The 29 included studies were conducted between 1994 and 2015 in diverse settings in 15 countries (9136 participants, mean age = 76.5 years ( SD = 8.1), 56% women). Most studies tested multicomponent interventions ( n = 26) to prevent delirium ( n = 19). Three-quarters of the 29 included studies ( n = 22) excluded various groups of people requiring palliative care; however, inclusion criteria, participant diagnoses, illness severity and mortality indicated their presence in almost all studies ( n = 26). Of these, 21 studies did not characterise participants requiring palliative care or report their specific outcomes (72%), four reported outcomes for older people with frailty, dementia, cancer and comorbidities, and one was explicitly focused on people receiving palliative care. Study heterogeneity and limitations precluded definitive determination of intervention effectiveness and only allowed interpretations of feasibility for people requiring palliative care. Acceptability outcomes (intervention adverse events and patients’ subjective experience) were rarely reported overall. Conclusion: Non-pharmacological delirium interventions have frequently excluded and under-characterised people requiring palliative care and infrequently reported their outcomes.

Introduction Delirium is a distressing condition which is commonly experienced by hospice patients. Although delirium can be prevented by around one-third in hospital inpatients (Siddiqi et al. 2016) there has been little research into effective strategies to prevent and manage delirium in hospices. Greater insight into the current practice attitudes and understanding of hospice staff and volunteers would inform the development of interventions that are tailored to improve delirium care in hospices. Aim To explore the understanding attitudes and practice of hospice staff and volunteers regarding the care of patients with delirium. Methods 36 qualitative semi-structured interviews were conducted at two hospices. Participants were purposively sampled to include different disciplines (9 health care assistants, 8 nurses, 5 doctors, 4 volunteers, 3 board members, 2 allied health professionals, 2 managers, 2 domestic workers and 2 fundraisers). A topic guide and case vignettes prompted participants to describe their experiences in relation to delirium prevention recognition assessment and management. Three researchers are conducting thematic analysis to identify analyse and interpret themes from the interview data. Results Provisional results include themes of: ‘Supporting the distressing experience of delirium’; ‘Management strategies’ and ‘The burden of delirium care.’ Gaps in current practice relate to delirium prevention recognition and screening. Potential facilitators for developing interventions in hospices include education flexibility in staffing the role of volunteers and a supportive staff culture. Conclusion This study will provide important insights into staff and volunteers’ current practice which will inform the development of a targeted intervention to improve delirium care in hospices. Reference . Siddiqi N, Harrison J, Clegg A, Teale E, Young J, Taylor J, Simpkins S. Interventions for preventing delirium in hospitalised non-ICU patients. Cochrane Database of Systematic Reviews2016;(3). Art. No.: CD005563. doi:10.1002/14651858.CD005563.pub3

BACKGROUND:Bipolar disorder is not uncommon, is associated with high disability and risk of suicide, often presents with depression, and can go unrecognised. AIM:To determine the prevalence of unrecognised bipolar disorder among those prescribed antidepressants for depressive or anxiety disorder in UK primary care; whether those with unrecognised bipolar disorder have more severe depression than those who do not; and the accuracy of a screening questionnaire for bipolar disorder, the Mood Disorder Questionnaire (MDQ), in this setting. DESIGN AND SETTING:Observational primary care study of patients on the lists of 21 general practices in West Yorkshire aged 16-40 years and prescribed antidepressant medication. METHOD:Participants were recruited using primary care databases, interviewed using a diagnostic interview, and completed the screening questionnaire and rating scales of symptoms and quality of life. RESULTS:The prevalence of unrecognised bipolar disorder was 7.3%. Adjusting for differences between the sample and a national database gives a prevalence of 10.0%. Those with unrecognised bipolar disorder were younger and had greater lifetime depression. The predictive value of the MDQ was poor. CONCLUSION:Among people aged 16-40 years prescribed antidepressants in primary care for depression or anxiety, there is a substantial proportion with unrecognised bipolar disorder. When seeing patients with depression or anxiety disorder, particularly when they are young or not doing well, clinicians should review the life history for evidence of unrecognised bipolar disorder. Some clinicians might find the MDQ to be a useful supplement to non-standardised questioning.

Universal health coverage (UHC) is at the heart of the new 2030 Agenda for Sustainable Development. Health service integration is seen by World Health Organization as an essential requirement to achieve UHC. However, to date the debate on service integration has focused on perceived benefits rather than empirical impact. We conducted a global review in a systematic manner searching for empirical outcomes of service integration experiments in UHC countries and those on the path to UHC. Sixty-seven articles and reports were found. We grouped results into a unique integration typology with six categories - medical staff from different disciplines; patients and medical staff; care package for one medical condition; care package for two or more medical conditions; specialist stand-alone services with GP services; community locations. We showed that it is possible to integrate services in different human development contexts delivering positive outcomes for patients and clinicians without incurring additional costs. However, the improved outcomes shown were incremental rather than radical and suggest that integration is likely to enhance already well established systems rather than fundamentally changing the outcomes of care.