After Action Reflective Report On Sandra’s Mother

INTENT

The intended outcomes for Sandra’s mother were to stabilize her blood pressure and treat a urine infection, which had been generated as a result of catheterization. Sandra’s mother would have been expected to have prompt use of validated delirium screening tools (such as the Confusion Assessment Method or 4AT) owing to her vulnerability (including because of age, risk of infection and recent surgery) (Lin et al., 2023). Early signs of delirium can be identified and deterioration prevented if these tools are used within 24 hours of hospital admission (Wilson et al., 2020). She should have been stabilized clinically with control of her blood pressure and urine infection, close, constant monitoring for change in cognitive status and her delirium.

As part of her routine care, she should have had regular assessments for signs of delirium, cognitive decline, or changes in behaviour. Intended outcomes included monitoring of vital signs, medication and infection markers, and clear communication between healthcare professionals and family members for help in identifying small changes in her condition (Lightfoot et al, 2019). The possible best practice would be continuous cognitive monitoring and reassessment during her stay until any deterioration to her mental state was detected. With this proactive, structured approach, complications would be prevented, and her recovery would follow established post-surgery care protocols. However, this was an approach that should have had time to detect and manage delirium promptly, whether it was in the form of confusion or agitation, so that recovery would occur within 2-3 days, as was supposed

OUTCOME

The actual events unfolded much differently than anticipated, with Sandra’s mother experiencing a complicated recovery marked by delirium. After a urinary tract infection, she was catheterized and became increasingly confused, agitated and disoriented. The family had noted several times how they thought her cognitive state was deteriorating but had been told that the changes were just normal post-operative confusion and that they were being poured over the physical symptomology. This lack of immediate recognition led to further deterioration in her condition, especially with her becoming more confused and emotionally distressed (Finucane et al., 2018). Sandra’s mother could not remember how she got into the hospital, and subsequently she was scared and disoriented.

The experience was emotionally stressful for Sandra and her family. The family was growing increasingly frustrated at the way the healthcare staff were not attending to their concerns. Sandra’s mother’s confusion grew worse, and they could only feel helpless, causing fear and emotional exhaustion for everyone involved. Despite Sandra’s advocacy efforts, it was not until she discovered the delirium toolkit that the condition was recognized and treated. Delirium in this case not only delayed the patient’s psychological suffering, but also harmed the family’s trust in the healthcare system (Racine et al., 2019). It became evident that what was provided by standard care protocols was far away from what really happens in clinical practice, especially in elderly patients which is why it is difficult to identify and manage delirium in elderly patients once it is unfruitful in diagnosing and treating early

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EVALUATION

Clinical Assessment Gaps

Initial risk assessment and neurosurgery ward screening protocols were inadequate in terms of delayed recognition of delirium. The patient had multiple well documented risk factors including advanced age, major surgery, and subsequent infection but systematic delirium screening was not routinely initiated early in the patient’s care journey. However this is at odds with best practice guidelines, which recommend early detection and intervention (Hoch et al., 2022). Missed opportunities for early intervention for and prevention of delirium progression were due to the failure to use standardized screening tools and regular cognitive assessments.

Communication Barriers

Lack of Communicationbetween family observations and healthcare provider response was an important factor in poor suboptimal outcomes. Timely intervention and allowing family concerns about behavioural change to be addressed would have been this missed opportunity. The role of family members in detecting early signs of delirium prior to the formal assessments is always underlined in research (Wilson et al., 2020). This pattern of healthcare team tendency to minimize these concerns as just ‘normal confusion’ is indicative of the broader problems in healthcare communication and the underutilization of family input in patient care evaluation.

System Limitations

The presence of limited expertise to manage delirium and restrictive visiting policies that impaired the patients’ recovery severely limited the management of delirium on the neurosurgery ward. Resource limitations and coordination challenges between departments within the hospital lead to a 10-day delay in transferring the patient to a more suitable care environment in addition to significant barriers to optimal care exemplified by a 10-day delay in transferring the patient to a more suitable care environment (Lightfoot et al., 2019).

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Improve

Enhanced Screening Protocols

Early detection and intervention are very crucial across all hospital unit and standardized delirium screening can be done using tools like Confusion Assessment Method (CAM) or 4AT. Since, staff may lack needed expertise, delirium can be under recognized in specialized units, such as neurosurgery wards, particularly in older patients. Staff training on how to use the tools would be tremendously successful in helping them identify early signs of delirium sooner, so they could intervene more quickly (Hoch et al., 2022).

Family Partnership

Early detection of cognitive changes is critical to patient assessment and care planning; and, family observations should be incorporated into patient care planning, as family members are often the first to notice the subtle behavioural changes. If ways could be formalized to integrate family input, through for example flexible visitation policies and regular family conferences, then concerns or observations could be brought to the fore and acted upon quickly (Finucane et al., 2017). This partnership between healthcare providers and families would fill communication gaps that offer more holistic patient care in addressing physical and cognitive aspects of care.

System Coordination

Clear pathways must be established to avoid delays in transfer of appropriate care between specialized units and elderly care facilities in order to avoid delays in delivery of appropriate care. If delirium is detected, rapid transfer to settings that can treat it is indicated. By working with interdisciplinary care teams consisting of specialists in geriatric care, expertise gaps across departments may be bridged to facilitate smooth transitions of care and better patient outcomes (Racine et al., 2019). This would enable to overcome the systemic problems that cause delays in intervention and effective care coordination.

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REFERENCES

Finucane, A. M., Lugton, J., Kennedy, C., & Spiller, J. A. (2017). The experiences of caregivers of patients with delirium, and their role in its management in palliative care settings: an integrative literature review. Psycho-oncology, 26(3), 291–300. https://doi.org/10.1002/pon.4140

Hoch, J., Bauer, J. M., Bizer, M., Arnold, C., & Benzinger, P. (2022). Nurses’ competence in recognition and management of delirium in older patients: development and piloting of a self-assessment tool. BMC Geriatrics, 22(1). https://doi.org/10.1186/s12877-022-03573-8

Lightfoot, M., Sanders, A., Burke, C., & Patton, J. (2019). Clinical Pharmacist Impact on Intensive Care Unit Delirium: Intervention and Monitoring. Hospital pharmacy, 54(3), 180–185. https://doi.org/10.1177/0018578718778226

Lin, C., Su, I., Huang, S., Chen, P., Traynor, V., Chang, H., Liu, I., Lai, Y., Lee, H., Rolls, K., & Chiu, H. (2023). Delirium assessment tools among hospitalized older adults: A systematic review and metaanalysis of diagnostic accuracy. Ageing Research Reviews, 90, 102025. https://doi.org/10.1016/j.arr.2023.102025

Racine, A. M., D’Aquila, M., Schmitt, E. M., Gallagher, J., Marcantonio, E. R., Jones, R. N., Inouye, S. K., Schulman-Green, D., & BASIL Study Group (2019). Delirium Burden in Patients and Family Caregivers: Development and Testing of New Instruments. The Gerontologist, 59(5), e393–e402. https://doi.org/10.1093/geront/gny041

Wilson, J. E., Mart, M. F., Cunningham, C., Shehabi, Y., Girard, T. D., MacLullich, A. M. J., Slooter, A. J. C., & Ely, E. W. (2020). Delirium. Nature reviews. Disease primers, 6(1), 90. https://doi.org/10.1038/s41572-020-00223-4

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