Why ACE-T
The gap after the screen
Tools for detecting delirium are well established. What should happen in the first hours after a positive screen, and who should do it, has been far less clearly defined. ACE-T describes the nursing part of that response.
Delirium is common and serious
Delirium is a sudden change in attention and thinking that develops over hours or days and often fluctuates. Some people become agitated; others become quiet and drowsy, which is easier to miss.
About 20 to 30% of people on hospital medical wards have delirium. Compared with people who do not develop it, people with delirium are more likely to stay longer in hospital, to have falls and pressure sores, to need long-term care, to have a higher incidence of dementia, and to die.
Treatment advice varies
The ACE-T manuscript’s review identified several labels for delirium treatment in guidelines:
- multicomponent non-pharmacological interventions
- a multicomponent program
- non-drug strategies
- established pathways of good care
The content ranges from two brief recommendations to a programme of 15 components. Most guidelines do not say which professional group is responsible for which action. The few that assign roles still do not specify the order or timing of nursing actions in the hours after a positive screen.
Why nurses
Nurses are there when the screen is positive
In many health systems, nurses carry out most delirium screening. They can respond promptly to a positive screen and involve the rest of the team.
Nurses also carry much of the ongoing care of a person with delirium: managing interventions, monitoring distress, talking with families and keeping the person safe. Studies reviewed in the ACE-T manuscript reported gaps in escalation and action after positive screens, and in telling patients and families about the diagnosis. Source and publication status.
ACE-T gives nurses a practical, shared starting point for those first hours. Medical assessment and the wider team’s work continue alongside it.
What ACE-T asks of a nurse
- Consider observations, comfort and familiar checks
- Check whether investigations and a medication review have happened
- Assess distress and the care environment
- Document delirium or suspected delirium, with the score
- Communicate with the team and the family, escalating concerns under local policy
Diagnosing the cause, and ordering investigations outside local policy, stay with the team members whose role covers them.
Content and use
What the form includes
A clear place to start
When the screen is positive, you know what to look at first, on one page, without searching through a long protocol.
Familiar checks in one list
Observations, glucose, bloods, retention, constipation, hydration, nutrition, infection, pain and medicines, all in one list.
Attention to the person
Distress, agitation, reassurance, sensory aids, the environment and the people who know the patient are part of the response.
Delirium in the record
Documenting “delirium” or “? delirium” and the score makes it visible to everyone who reads the notes.
Structured communication
The score and findings go to the clinical team, the family is informed, and the plan is discussed with the multidisciplinary team.
A shared time frame
Four hours to complete, start or escalate what applies, with urgent concerns acted on at once.
Works with your screening tool
Use it after a positive 4AT, CAM or other locally used tool. Record whichever score your service uses.
Adaptable
The editable Word version lets services match local wording, roles and documentation.
Clear about scope
ACE-T supports nursing judgement and local policy. Use it with medical assessment and care from the wider team.
What staff said
Rated clear, usable and helpful
Before ACE-T was used with patients, 53 staff at the three pilot hospitals reviewed it: 26 nurses, 19 physicians and 8 advanced practice providers. Most rated it favourably.
Twenty-one of 52 (40%) found at least one section unclear or difficult, and their comments shaped the version on this site. Read how the feedback changed ACE-T.
These ratings describe what staff thought of the tool on paper. They are not measurements of how it performed at the bedside.
Staff ratings of the provisional tool
A useful term
Multidomain treatment
The ACE-T paper uses multidomain delirium treatment for the package of actions that makes up routine delirium treatment: finding and addressing triggers, managing symptoms and supporting recovery.
The term avoids dividing treatment into “non-pharmacological” and “pharmacological” parts. Guidelines advise against giving psychotropic drugs routinely, and allow brief, targeted use for severe distress that other measures have not relieved, or for safety. Medicines are therefore one optional part of a wider set of actions.
ACE-T covers the nursing part of multidomain treatment in the first hours.
Where the 4AT fits
Detect with the 4AT, respond with ACE-T
The 4AT is a short bedside test for delirium. Its four items cover Alertness, the AMT4 (age, date of birth, place and year), Attention (months of the year backwards) and Acute change or fluctuating course. Special training is not required, but users need knowledge of delirium.
A score of 4 or more suggests possible delirium and needs clinical assessment. Scores of 1 to 3 suggest cognitive impairment. A score of 0 makes delirium or moderate to severe cognitive impairment less likely. A low score does not rule out delirium: assess further if the history or clinical findings raise concern. ACE-T can guide the initial nursing response when delirium is suspected.
NICE recommends the 4AT when indicators of delirium are identified in hospital or long-term care. In critical care, or in the recovery room after surgery, it recommends the CAM-ICU or ICDSC instead.
The official 4AT user guideScope
What ACE-T does not do
- It does not detect delirium. Use the 4AT or your local screening tool for that.
- It does not make a diagnosis. A positive screen needs clinical assessment.
- It does not cover every part of delirium treatment. The team plan continues after the first hours.
- It is not a delirium prevention programme.
- It does not replace medical assessment or the work of other professions.
Evidence so far
ACE-T has been through staged development and a small pilot in three hospitals. Staff ratings were positive, and delirium was documented more often after it was introduced at all three sites.
The pilot did not measure patient outcomes, and its samples were small and not random. The authors recommend a prospective feasibility study before testing clinical effectiveness.
Pilot results and limitations