Differentials and investigations

Common Ward Calls

Overview and approach

This page holds your approach to common ward calls, starting with delirium; the Australian standard is the ACSQHC Delirium Clinical Care Standard (1).

  • Delirium is an acute, fluctuating disturbance of attention and cognition; screen at-risk patients (age 65 or over, 45 or over for Aboriginal and Torres Strait Islander people, cognitive impairment, severe illness, hip fracture) and assess promptly after any acute change (1).
  • Other ward calls have their own pages: Fall Ward Call, Seizure Ward Call, After Hours.

Delirium

Definition
  • Acute onset and fluctuating course
  • Inattention
  • either disorganised thinking or an altered level of consciousness
Assessment and clinical features

Screen with the 4AT; confirm with a structured delirium assessment such as the 3D-CAM (1)(2).

  • 4AT: a score of 4 or more suggests possible delirium; 1-3 suggests cognitive impairment (1). 3D-CAM and 4AT both performed well in an Australian post-anaesthetic validation study (2).
  • Look for causes (UTI: bladder scan) and complications (death, falls, increased care, dementia) (3).
Epidemiology / Cause

Causes

  • UTI - bladder scan
Risk Factors / Complications

Complications

  • death
  • falls
  • requires increased care and support
  • developing dementia
Clinical features
  • 4AT: possible delirium
  • 3D-CAM: confirm delirium
Differentials and investigations

Look for the trigger: infection, medicines, pain, retention, constipation, dehydration, hypoxia, metabolic disturbance and withdrawal (3). The septic screen and bloods are listed in your Management toggle below. Alcohol withdrawal delirium is outside the ACSQHC standard; see the Delirium page (1).

Management and follow-up

Treat the cause and use non-drug measures first (1)(3).

  • Your non-drug list: fiddle/busy blanket; hearing aids and glasses in place, adequate lighting; bed alarms; 1:1 special care; avoid physical restraint where possible as it worsens delirium, and discuss with the registrar.
  • Routine antipsychotic use is not recommended for delirium (2021 ACSQHC standard); if a drug is used, give it orally first, IM if oral is unsafe, never IV, and confirm indications and doses with a senior and local guidance (1). Drug notes are kept below.
Management

Investigations

  • Septic screen
  • Bloods: FBC, UEC, LFT, CMP, CRP

Non-pharm

  • fiddle/busy blanket
  • Make sure hearing device in place, making sure he is not visually impaired, adequate lighting
  • Bed alarms
  • 1:1 special care
  • Avoid physical restraint when possible as these worsen delirium, chat to Reg

Pharmacological management

  • Oral medications first (Haloperidol, Quetiapine (for parkinson pts), Olanzapine, Risperidone)
  • IM next if oral route not safe (Haloperidol or Olanzapine)
  • Never IV medications

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Red flags and clinical pearls

New confusion is a medical problem until proven otherwise; delirium raises the risk of falls, longer stay and death (3).

  • Always exclude hypoglycaemia, hypoxia, sepsis, retention and medicine effects first.
  • Never leave a delirious patient unobserved without a plan; avoid restraint where possible.
References
  1. ACSQHC: Delirium Clinical Care Standard (revised 2021)
  2. Validation of 3D-CAM and 4AT for detecting delirium in older patients in the post-anaesthetic care unit (IJERPH 2022)
  3. healthdirect Australia: Delirium

Last updated from Sen’s notes on 9 October 2026.