Delirium is under-recognised but is surprisingly a common problem, particularly among older people who are hospitalised. People who have delirium have trouble thinking clearly, focusing their thoughts, and paying attention. It can be frightening, however there are many ways it can be prevented or properly managed. Usually a direct cause can be identified, such as medication, an infection, dehydration, and kidney failure.
If left untreated, delirium can have serious consequences for a patient's recovery.
What are we trying to achieve?
Delirium is a common but often missed or misdiagnosed illness in our hospitals and is associated with significant morbidity and mortality.
Our Aim: Reduce the prevalence of delirium by 30% amongst patients at Waitemata DHB in selected wards at North Shore and Waitakere Hospitals.
What did we find?
We undertook an extensive point prevalence audit to determine the prevalence of delirium across the organisation.
What is a point prevalence audit?
It's a measure of the proportion of people in a population who have a disease or condition at a particular time, such as a particular date. It is like a snap-shot of the disease in time.
Point prevalence can be described by the formula:
Number of existing cases on a specific date
Number of people in the population on this date
Prevalence audit process
We designed the following 3 stage audit tool:
- Mini-mental state examination (MMSE) that comprised of a series of general knowledge questions, e.g. what is the year? This test enables us to determine if the patient is cognitively impaired. If the patient has a score from the MMSE that is less than 24 there is a high likelihood that the patient is cognitively impaired.
- If the patient has a MMSE score of less than 24 we conduct a confusion assessment method (CAM) test which shows us if the diagnosis of delirium is likely (CAM positive).
- If the patient is CAM positive a Memorial Delirium Assessment Scale (MDSA) is used to determine the severity of the patient's delirium.
Delirium Prevalence Audit Methodology flowchart
Prevalence audit of Waitemata DHB services
We chose three wards to audit patients over 65 years old or 55 years old for maori/pacific. We selected a single ward from each of the following services:
- AT&R (Assessment Treatment & Rehabilitation)
The audits were undertaken by 9 clinical experts (3 per ward).
The project team found the following percentage of patients showed cognitive impairment (MMSE less than 24):
- 42% of medical patients
- 24% of surgical patients
- 49% of AT&R patients
Of these patients, the delirium rate ranged from 7.7% to 14.8%:
- Medical Ward Delirium Prevalence = 14.8%
- Surgical Ward Delirium Prevalence = 8.2%
- AT&R Ward Delirium Prevalence = 7.7%
Delirium cause & effect diagram
We held several issues workshops with staff to identify factors that contribute to delirium. We organised these factors into a cause and effect diagram. Over 400 discrete issues were identified.
Using the cause and effect diagram to identify common themes, we were then able to prioritise four key areas of focus:
- Assessing risk and making a diagnosis
- Minimising confusion
- Modifiable risk factors
- Medication management
What have we done?
The following solutions were identified by each working group.
1. Assessing Risk and Making a Diagnosis
i. Risk and diagnosis algorithm
Description: Development of a risk & diagnosis algorithm flowchart to be used with patients to determine if they are at risk or or have a delirium
Status: Awaiting implementation organisation wide
Delirium risk & diagnosis algorithm
ii. Assessment and diagnostic unit (ADU) initial risk assessment process
Description: Creation of a process to ensure an initial risk assessment and examination for indicators of delirium is done in ADU and Emergency Departments (ED). Recommendations for cognitive assessment are then put into a medical plan rather than in a separate form.
Status: Awaiting feasibility decision
iii. Cognitive testing tool
Description: We developed a cognitive test that can be used by anyone in the multi-disciplinary team (MDT). This informs the CAM (delirium screen).
Status: Awaiting feasibility decision and inclusion into the admission to discharge (A-D) planner
iv. Staff e-learning tool
Description: We discovered delirium was not a focus in junior medical staff teaching. Educators consider it is one of the top 10 required subjects. An e-learning package has been developed.
Status: Included in teaching programme
2. Minimising confusion
i. Clocks and calendars
Description: A clock audit has shown several rooms without clocks, and where clocks are present not all patients can read them. Calendars identifying the day of week are also a key recommendation to assist with patient's orientation. These can be combined using large clocks with in-build calendar functions.
Status: Under investigation
ii. Orientation sheet
Description: At risk patients need cues to assist them with their orientation in terms of their environment. We worked with the "Falls prevention and management" project to include visual cues in the new patient information sheet located at each patient's bedside.
New patient information sheet
iii. Family information brochure
Description: Involving family in cognitive stimulation, orientation and reminiscence is a key recommendation. Such cues can be tailored by family members (e.g. bringing in family albums). We developed a brochure to provide families with clear guidance and support on how they can help.
Delirium Information for Patients, Family & Friends brochure
[click on brochure to download a copy]
iv. Sensory aids
Description: Many patients do not bring their hearing aids or spectacles into hospital. This sensory deprivation is a key modifiable risk factor for delirium. We would like to make sound amplifiers available for patient use.
Status: Awaiting feasibility decision
v. Update constant observation form
Description: The constant observation form is used to instruct those doing 1:1 observations on patients. This form is often used when delirious patients require close observation. The form needed updating with key interventions from delirium guidelines such as cues to orientation, conversation topics and addressing sensor impairment.
Constant observation form
3. Modifiable risk factors
i. High delirium risk / CAM positive sticker for notes
Description: Patients with a high delirium risk and a CAM positive status need to be easily identified in the patient's notes. We have created a sticker that emphasises and prompts staff on particular preventative and delirium reduction strategies.
Status: Currently being piloted
4. Medication management
i. Drug treatment protocol for delirium
Description: Medication chart audits showed that we use a lot of potentially deleriogenic medications when less deleriogenic alternatives or better regimens could be used. We also don't use medication well to manage delirium. This protocol combines both of these elements into a single guideline.
- Deleriogenic means anything that can cause delirium such as certain medications, the environment (e.g. noisy rooms) and medical conditions (e.g. concussion, infection)
Drug treatment protocol for delirium
ii. Delirium sticker post-operative nausea and vomiting (PONV) guidelines
Description: We updated the existing sticker for PONV guidelines to raise prescribers' awareness of high-risk or delirious patients and prompt a delirium-specific review by inpatient pharmacists.
iii. Update of nausea and vomiting protocol
Description: Medications to manage nausea and vomiting, especially post-operatively, can precipitate delirium, e.g. cyclizine. When patients are a high delirium risk, better alternatives can be used. The existing protocol has been updated to reflect this.
iv. Input into pain e-learning module
Description: Poor use of opiates and opiate-sparing medications is a key delirium precipitant. An e-learning module on good pain management has been developed and we have included pain medication prescribing for patients with delirium.
v. Pharmacy education module
Description: Our pharmacists review medication charts from a delirium perspective and offer advice to prescribers. It is important that the pharmacists are up to date with best practice. A delirium education module has been developed and is being used at both pharmacy orientation and in service training.
Did we make a difference?
Overall there was a 7.4% reduction in the prevalence of delirium in the 3 wards (Mar 2012 - Jul 2013).
Where to from here?
Although the fortnightly point prevalence audit has stopped, work is still continuing on several solutions related to this project.