Acute Triggers
What might be causing or worsening the delirium?
- Observations and conscious level
- Blood glucose and routine blood tests
- Retention, constipation, hydration and nutrition
- Infection, pain and medicines
For nurses · Delirium care
Clear first steps after a positive delirium screen
ACE-T is a one-page nursing tool for the first hours after delirium is detected. It helps you look for acute triggers, attend to the patient’s experience, and start treatment and communication with the team.
Evidence is from an early development pilot. Its effect on patient outcomes has not been established. Read the results and limitations.
The tool
Three domains, started together
ACE-T groups the early nursing response into three domains. You work through them in parallel, using your clinical judgement about which actions apply to the person in front of you.
Patient Experience
How is the person feeling, and what would help?
- Distress and agitation
- Reassurance and reorientation
- Glasses, hearing aids and a calm space
- Relatives, friends and carers
Treatment
What does the person need now, and who needs to know?
- Falls risk and immediate support
- Document delirium and the 4AT score
- Tell the clinical team and the family
- Agree the plan with the team
Timing
Aim for four hours
Complete, start or escalate the actions that apply within four hours of the positive screen. Four hours is a practical target for the whole initial response. It is not a safety threshold.
Urgent concernsAct on them immediately and escalate through your local pathway.
In parallelThe three domains can be worked on at the same time, by more than one person.
Then keep goingRepeat relevant actions as the person’s condition changes, and hand over what is outstanding.
Where ACE-T fits
From a positive screen to a shared plan
Detection tools such as the 4AT tell you that delirium may be present. ACE-T describes the initial nursing actions, alongside medical assessment and the rest of the team.
Step 1
Positive screen
A 4AT score of 4 or more, a positive result on your local screening tool, or clinical recognition of suspected delirium.
Step 2 · Start ACE-T
ACAcute TriggersLook for problems that may be causing or worsening the delirium.
EPatient ExperienceRecognise distress, reassure, and support communication.
TTreatmentSupport the person, document delirium and share the plan.
Step 3
Shared plan
Delirium documented, the team and family informed, and a treatment plan agreed. Care then continues beyond the first four hours.
Nursing actions
What the bedside form includes
A clear place to start
The first nursing actions after a positive screen, together on one page.
Familiar checks, brought together
Prompts to assess blood glucose, urinary retention, constipation, hydration and pain appear together on the form.
Attention to the person
Distress, reassurance, glasses and hearing aids, a calmer space, and the people who know the patient.
Delirium made visible
Writing “delirium” or “? delirium” and the score in the record means everyone who reads the notes can see it.
A team response
Findings go to the clinical team, the family is informed, and the plan is agreed with the multidisciplinary team.
Fits your setting
Use it with the 4AT or your local screening tool. The Word version can be edited to match local wording and policy.
From the pilot
Piloted in three hospitals
ACE-T was refined with feedback from hospital staff and then introduced at the Royal Infirmary of Edinburgh, AGAPLESION Markus Krankenhaus in Frankfurt, and Stanford Hospital in California.
53
staff reviewed the tool before it was used: 26 nurses, 19 physicians and 8 advanced practice providers.
3 in 4
staff rated ACE-T easy or very easy to use (39 of 52), and 41 of 53 rated its steps clear or very clear.
9–10 of 10
reviewed records at each hospital documented delirium after ACE-T was introduced, compared with 0 to 3 of 10 before.
This was an early developmental pilot with small, non-random samples of records. It describes staff views and what was written in the notes. It did not measure patient outcomes. What the pilot found, and its limits.
The story
How ACE-T came to be
Tools for detecting delirium are well established. What a nurse should do in the first hours after a positive screen has been much less clear. ACE-T began in Edinburgh as an attempt to write that response down, and grew into a collaboration between clinicians in the UK, Germany and the United States.
Read the story of ACE-TTake ACE-T to your ward
Print the one-page bedside form, adapt the Word version to your local wording, or put the overview poster up in the staff area.