WEBVTT

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You have just completed a delirium
screen and the result is positive.

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Alongside arranging clinical assessment,
you need to decide what to do now.

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What might be contributing?

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How is the patient feeling?

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What needs to be communicated?

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ACE-T brings these early nursing
actions together, so you have a

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clear place to start.

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The problem is not a shortage
of advice about delirium.

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Research papers and clinical protocols
recommend quite different combinations

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of actions, often without clearly saying
who should carry them out, or when.

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ACE-T was developed to make the initial
nursing contribution more explicit.

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It supports a team response
rather than asking nurses

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to manage delirium alone.

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There are three sections: Acute Triggers,
Patient Experience, and Treatment.

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This is a tool for the treatment of
delirium, not a delirium prevention

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programme. It follows a positive
detection result; it does not make the

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diagnosis. Use it alongside clinical
assessment and your local delirium

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pathway, not as a replacement for either.

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The aim is to address the relevant
suggestions within the first four hours

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after detection. That gives the
early response a time frame.

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It does not mean waiting four hours to
act, and it is not a validated safety

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threshold. Escalate urgent
concerns immediately.

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The sections can be used
together; they are not a queue.

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Begin by checking observations:
pulse, blood pressure,

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oxygen saturation, respiratory rate,
temperature, and conscious level.

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Check capillary blood glucose and whether
routine blood tests have been sent.

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Escalate abnormal findings as required.

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If further investigations are needed,
discuss these with the appropriate

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clinician, following local policy
and your scope of practice.

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Assess for urinary
retention and constipation.

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Review hydration, nutrition, and pain.

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Consider infection assessment where
clinically indicated, rather than routine

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urine testing for every
positive delirium screen.

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Check whether medication
review has been completed, and

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raise possible medicine-related problems.

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The tool helps you bring
together findings, gaps, and

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concerns that need action.

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Now consider the patient’s experience.

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Observe for distress, ask how they
are feeling, and note any agitation.

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The Quick Distress Assessment Tool
may be useful where appropriate.

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Its questions are simple:
“How are you feeling?

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Is anything bothering you?”

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A patient does not have to be
agitated to need reassurance

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or help with distress.

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Offer reassurance and reorientation.

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Explain who you are and what is happening.

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Check that glasses, hearing aids, and
other communication aids are available.

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Consider the environment, including
whether a single room is needed.

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Involve relatives, friends,
or carers where appropriate.

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These suggestions keep the person’s
experience in view while the team

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assesses and treats contributing problems.

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For Treatment, consider falls risk
and immediate supportive measures.

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Fluids or oxygen may be needed,
but neither is an automatic response to

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delirium. Document delirium or
suspected delirium, as appropriate,

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and the local screening score.

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Remember that a positive screening result
requires clinical assessment; it is

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not, on its own, a confirmed diagnosis.

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Communicate the score and relevant
findings to the clinical team.

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Inform the family and provide a delirium
leaflet to the patient and family

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where appropriate. Discuss the treatment
plan with the multidisciplinary

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team. Your nursing care and observations
complement the work of doctors,

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advanced practitioners, therapists,
pharmacists, and other colleagues,

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according to local roles.

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ACE-T is a set of suggestions, not an
instruction to do every item for every

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patient. Use your professional judgement
about what is needed, what should be

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added, and what is unnecessary.

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Wording may differ by setting or country.

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Relevant actions can be repeated during
ongoing care; treatment does not stop

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when four hours have passed.

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The early pilot produced encouraging
staff feedback, not proof of improved

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patient outcomes. Think of ACE-T as
a brief prompt for a more explicit

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nursing response: look for acute
triggers, attend to the patient’s

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experience, and bring treatment
and communication together.

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Take a look with your team,
and consider using it with

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the next suitable patient.