Shifting the focus: A QI project to improve the management of delirium in patients with hip fracture

Abstract

Methods The project was completed at a 343-bedded district general hospital in the London borough of Hackney. The intervention was carried out on all surgical wards (n=2) accepting emergency surgical admissions. These wards included patients under the care of a wide range of surgical specialties; however, the project focused on those admitted with NOF fracture. The project followed 'plan, do, study, act' (PDSA) methodology. 9 A steering group, led by a consultant geriatrician, was set up to complete the project. Other members included a psychiatry registrar, a geriatric medicine registrar, specialist nurses (in dementia and orthopaedics), a physiotherapist, an occupational therapy assistant and surgical ward managers. The steering group developed a three-step pathway for the assessment and management of delirium (see Fig 1) over a 2-month period. This was based on national guidelines which were adapted to meet local needs. A strategy for its delivery was devised, including embedding 4AT into the patients' electronic records (Cerner) and an educational programme for clinical staff (see Fig 2). This was implemented in December 2017. The effectiveness of the intervention was assessed using a review of the electronic notes system (Cerner). All patients admitted to the surgical wards (at any point during their admission) with a NOF fracture, in the 6 months (January-June 2018) post implementation were included in the analysis. This was compared to a control group of patients. Patients were included in the control group if they had been admitted to the surgical wards (at any point during their admission) with a NOF fracture in the 6 months of January-June 2017. This control group was selected in order to minimise the variation that is likely to occur in this group of patients and the number of admissions in summer and winter months. The primary (process) measure was the use of the 4AT. Secondary measures included outcome measures comprising key performance indicators; length of stay, mortality, change in discharge destination (not including increase or change in care package) and coding on the discharge summary. Staff confidence was also measured pre-and post intervention via questionnaires. Control group data were collected throughout 2017. Post-intervention group data were collected after small group lectures in December 2018. Staff were tested on their ability to name delirium risk factors (as defined by inclusion in the NICE guidelines and or PINCH ME mnemonic) and confidence regarding delirium (diagnosis and explanation) using a Likert scale (1-5). In addition, doctors were asked to name any local or national guidelines. Data were analysed using GraphPad Prism software. Fig 1. Three-step pathway for the assessment and management of delirium. Remember the SQiD Is this paaent more confused or drowsy than normal? Think delirium.