Improving the quality of delirium practices in a large Australian tertiary hospital: An evidence implementation initiative

Abstract

Objective: The aim of the evidence implementation initiative was to improve the quality of care delivered to hospitalised patients at risk of, or with, delirium through the implementation of best practice recommendations. Background: Delirium is a prevalent serious medical condition that remains unrecognised or misdiagnosed in acute hospitals and is therefore left untreated. This paper reports on a hospital-wide quality improvement project which was undertaken in recognition of the Australian Delirium Clinical Care Standard and as a response to the cumulative rate of hospital-acquired delirium within a health organisation in New South Wales, Australia. Methods: The quality improvement project used the JBI (formerly known as Joanna Briggs Institute) evidence implementation framework. Briefly, the JBI evidence implementation approach is grounded in the audit, feedback and re-audit process along with a structured process for the identification and management of barriers to compliance with recommended clinical practices. Twelve nurses, who received support from external facilitators (implementation researchers), acted as delirium champions. Results: Baseline audit of 143 patient notes showed poor compliance (range 6% – 67%) to recommended practices relating to screening, assessment, prevention and management of delirium. Barriers analysis revealed nurse-related (eg. lack of knowledge) and organisational level factors (e.g. absence of a hospital-wide policy/procedure for delirium management). A multicomponent strategy was implemented by all delirium champions in their respective units/wards. Follow-up audit of 151 patient notes demonstrated significant improvements in compliance with best practice recommendations for all aspects of delirium care. Discussion: The quality improvement activity highlighted that education remains one of the most important and critical first steps in facilitating change in clinical practice. Critical to the success of the project was the collaborative approach of the delirium champions across various specialties, which allowed for the sharing of expertise, knowledge and consensus-based decision making. The facilitation provided by the delirium champions and external facilitators was also a vital ingredient for the successful implementation of evidence-based practices. Conclusion: The quality improvement activity has improved nurses’ screening and assessment of patients at risk of or with delirium, leading to improvements in its prevention and management. Collaborative efforts within the organisation facilitated the development of a standardised, evidence-based tool for delirium screening, assessment, prevention and management, and staff education resources. Partnership with patients and/ or their families through education remains an area for ongoing improvement, as with discharge planning for patients with current or resolved delirium. What is already known about the topic? • Delirium care is a major challenge among healthcare practitioners and therefore the condition remains prevalent in many acute hospitals. In Australia, delirium has been identified as a high priority area for quality improvement. The Australian Commission on Safety and Quality in Health Care released the Delirium Clinical Care Standard to ensure that patients at risk of delirium are identified early and receive preventative strategies, and that those with delirium receive optimal treatment to address their condition. What this paper adds: • This paper offers a detailed approach for evidence implementation to improve the quality of care delivered to hospitalised patients at risk of or with delirium. Key enablers were strong leadership support, sharing of experiences and knowledge, and the collective effort to problem solve and develop tools and resources for delirium.