# Multiple Avenues for Delirium Education at UAB Lead to Improved Care

The BRAIN Project

Multiple Avenues for Delirium Education at UAB Lead to Improved Care

A summary of the BRAIN Project’s second Best Practice Accelerator Community session. See what University of Alabama Birmingham (UAB) shared about how delirium education is key to successful interventions.

How Delirium Education Builds Age-Friendly Culture

While UAB’s success can be attributed to many factors, reaching the entire staff has been critical. To achieve this, UAB started by incorporating an hour of 4Ms training into nursing orientation. They also offer all disciplines an intensive 3.5-hour bootcamp on age-friendly care.

For staff who need greater flexibility, UAB educators visit specific units to facilitate 15-minute group learning sessions. And for those clinicians interested in advancing age-friendly care, there are opportunities to extend learning and lead quality improvement projects — many of which have resulted in standardized screening protocols.

Another important driver of UAB’s success: all education is delivered during regular paid working hours.

Hartford HealthCare BPAC

Sharing Success and Fueling Innovation

UAB presented their incredible work at the second Best Practice Accelerator Community (BPAC) session. Bringing together a number of health systems, the session highlighted how consistent 4Ms education can foster an age-friendly culture — one that sustains a cycle of continuous improvement in care.

Before we explore these efforts in detail, it’s important to take a closer look at UAB.

About UAB

UAB Medicine is an academic healthcare system located in Birmingham, Alabama. UAB Hospital has more than 1,224 beds, with a staff of over 1,600 medical professionals, 4,200 nurses, and 1,200 technical and support personnel.

The system has a history of focusing on geriatric patients. It has been an ACE (Advanced Care for the Elderly) unit and NICHE hospital since 2008, receiving exemplar status with NICHE in 2014. In 2019, they became an Age-Friendly Health System, and in 2021 UAB Highlands was awarded Level 1 Geriatric Emergency Department Accreditation (GEDA).

Their work in education has also been exemplary. In 2002, UAB received the Magnet designation for nursing excellence and quality patient care — a designation they have now been awarded six times. Bolstering their reputation, UAB’s Geriatric Scholar Program has been recognized by Magnet as an Exemplar Program.

Embedding Age-Friendly Education

In order to reach all staff members, UAB must meet them where they are. They achieve this through a variety of mentation education strategies.

Each one centers on the why behind different approaches to delirium care, incorporating case studies where possible to put a human face on the learning. Once the case is established, the sessions get more specific about how interventions are carried out.

Mentation Education Strategies

Nursing Orientation

An hour-long presentation of the 4Ms is built into nursing orientation. All nursing staff are introduced to Age-Friendly Health Systems as a foundational part of their training, with a look at mentation and UAB’s delirium prevention and screening processes.

Age-Friendly Bootcamps

All staff have the option to participate in intensive 3.5-hour bootcamps on age-friendly care. UAB spreads the word through email, internal website messaging, leadership meetings, and word of mouth.

Unit-Level Education

Staff actively caring for patients need a unique solution. Over the last couple of years, UAB has found success with 15-minute learning sessions held at the unit level. Here, staff can rotate in and out during their shifts, and complete three training modules over a two-week period.

Geriatric Scholar Program

Even with a growing population of older adult patients, most personnel had not received in-depth training on how to care for older adults. UAB created the Geriatric Scholar Program to bridge that gap.

This interdisciplinary program brings together staff who are passionate about improving older adult care. Offered in one- or two-year tracks, the program equips participants with the knowledge, skills, and confidence to become agents of change within their sphere of influence. It’s not just about individual learning — it's about bringing that knowledge back to their units and putting it into practice.

The one-year track gives scholars the knowledge and confidence to advocate for best practices within their teams. For the two-year track, second-year scholars are asked to lead a quality improvement project. An interdisciplinary team of educators helps them find opportunities to integrate their age-friendly screens into the existing EHR.

The educators also advise on where the screens should live within the software, which assessments to use, how the screens should look within the order panels, and more.

Over the years, the geriatric scholar-led projects have informed screening protocols at different levels of care. Through the program, UAB has integrated screening for mobility, cognitive impairment, and frailty — alongside delirium screening and prevention strategies.

Universal Screening on Multiple Fronts

At UAB, universal screening begins on arrival. From there, distinct screening protocols assess various aspects of patient health, while being tailored to different care settings. By establishing a consistent baseline across the full patient population, UAB can then identify those with cognitive impairment, mobility challenges, frailty, and more.

Here’s an overview of the screening strategies.

Six-Item-Screener (SIS)

Embedded in the EHR, this screener is administered to every patient upon arrival regardless of age. It provides a baseline of their cognition on entry, which then lets clinicians identify any changes that arise during their visit.

While the SIS does not specify what’s causing the confusion — dementia, delirium, medication, or something else — it does indicate the presence of cognitive impairment. And that sets the clinician up to determine the underlying cause. It also flags the patient as high-risk for new or ongoing delirium and other adverse outcomes.

Nursing Delirium Screening Scale (Nu-DESC)

As with the SIS, this screener lives in the EHR. It’s used on all patients in the acute care setting and is completed at least once per shift by rounding nurses. For ease of use, it employs the same scoring system as the SIS. If the patient scores zero, it means cognitive impairment has not been detected. A score of two or more, on the other hand, means that cognitive impairment is present.

CAM-ICU

UAB uses this screener on all patients in critical care. It’s completed by nursing staff at least once per shift and is also embedded in the EHR. Unlike the Nu-DESC screener, the CAM-ICU flags patients as either “delirious” or “non-delirious”. There is also a dedicated panel for interventions. Here, nurses can log which interventions have been administered, and physicians can formally order them.

KATZ-ADL and Johns Hopkins Mobility Screen

In order to establish a baseline functional status, the nursing team will perform two more screens across inpatient settings: KATZ-ADL and Johns Hopkins Mobility Scale. These are administered upon admission and again once per shift. Together, they help the care team determine if there has been a change in functional capacity throughout the patient’s stay.

Additional Assessments

Beyond screening tools, UAB also assesses pain, an important part of determining a patient’s risk of developing delirium. The team considers whether they are undertreating or overtreating pain while also reviewing the patient’s medications — in case any are causing a change in cognition.

Connecting the Dots

Once staff have all the information, they use the following approaches to inform patient care.

ACE Tracker

To see the full picture of patient health, UAB uses the ACE (Acute Care for Elders) Tracker, which is embedded in the EHR. In a single view, the tracker displays all the risk factors for functional decline among older adults throughout a given unit.

Clinicians can quickly review whether the patient has a cognitive impairment diagnosis, along with SIS results, delirium screen outcomes, and functional assessments. They can also view baseline mobility, pain scores, Beers Meds, PT referrals, and more. The tracker also displays patient goals under ‘What Matters Most’. 

Transition of Care Rounds

Within each unit, an interprofessional team meets to discuss the information gathered on older adult patients. Consisting of physicians, nurses, pharmacists, therapists, and more, the team identifies patients at risk of developing delirium — or already presenting with it.

Preventing and Managing Delirium

Because delirium is multifactorial, there’s no one-size-fits-all solution for reducing it. Guided by screening data and team discussions, UAB staff employ a range of strategies to prevent and manage the condition.

STOP DELIRIUM Pathway

Staff are trained on the UAB STOP DELIRIUM Pathway, which contains steps to help prevent delirium. Structured as an acronym, STOP DELIRIUM helps the team address contributing factors through non-pharmacological interventions — from ensuring safe mobility to assessing metabolic abnormalities. Because these steps focus on prevention, they are carried out on an ongoing basis.

Watch the BPAC video for a full breakdown of each intervention.

Watch Video

Delirium Prevention Toolbox

Every nursing unit is equipped with a Delirium Prevention Toolbox. This contains items for cognitive stimulation: puzzles, crosswords, coloring sheets, and more. It also offers items for distraction, including teddy bears and activities that let patients fidget, along with ear plugs and hearing amplifiers. For added utility, each toolbox comes with educational resources for staff and families.

HELP Volunteer Program

To improve the patient experience, UAB has implemented the HELP Volunteer Program (Hospital Elder Life Program). Here, volunteers are educated in the 4Ms framework, with 10 hours of online learning and simulated patient training. They aid in orientation, cognitive stimulation, mobility, and nutrition, freeing up UAB staff to perform other critical tasks. This enables greater patient and staff satisfaction and, in some cases, can reduce the need for medication.

Delirium Order Set and PowerPlan

Although staff are instructed to continually practice the STOP DELIRIUM Pathway, UAB has hardwired these interventions into the EHR. A delirium order set allows clinicians to order non-pharmacological interventions for patients at risk of developing delirium. The PowerPlan allows them to do the same for patients testing positive for delirium.

Family Education and Support

For patients with delirium, bedside caregivers are given educational materials that help them understand what’s happening.

From Education to Practice

Delirium is a complex condition that disproportionately affects older adults. While there isn’t a single approach that prevents or resolves delirium, multiple low-cost, non-pharmacological approaches used together can reduce the risk — but consistency is critical to success.

UAB has shown that a culture of education creates the conditions for that consistency. By meeting staff at their level, the health system has successfully built delirium education in a way that reaches everybody. Not only has this informed screening protocols, but also the way in which teams recognize risks, share information, and carry out interventions.

For other health systems, UAB's work offers a clear lesson: education is most effective when it factors in the realities of frontline care. When staff can access information in a way that works for them, they’re more likely to be engaged and participate in a culture that puts best practice into action.

Dive Deeper

Watch the BPAC Session

Stream the full Best Practice Accelerator Community session for more information and discussion.

Watch BPAC Session

Part of the BRAIN Project

Creating Dementia and Delirium Friendly Hospitals

BPAC sessions are a key element of the BRAIN Project. The initiative brings the Alzheimer's Association and the Geriatric ED Collaborative together with the support of the West Health Institute. Its goal is to identify high-performing hospitals, understand how their models work, and translate those lessons into practical tools for other health systems to adopt.

BRAIN brings together leading hospitals to explore practical interventions for dementia and delirium in ED and inpatient settings. Successful approaches are shared through collaborative sessions and formalized. From there, health systems are equipped to transform care — translating what is already known into what is widely practiced.

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