Postoperative delirium is the most common surgical complication, occurring in 5-50% older patients(1). Delirium incidence with major joint surgery Musgrave Park Hospital(MPH), Belfast HSC Trust was initially reported as 1.1%, indicating an under recognition and prompted a multidisciplinary leadership approach. Local MPH figures indicate consequences of postoperative delirium include increased morbidity with prolonged hospitalisation (4 fold) and 40% increased discharge to place other than usual residence eg nursing home(2). As delirium is preventable in up to 40% of patients(3), a Delirium Steering Group with a collective leadership approach, was established in orthopaedics MPH.
The aim was to nurture early identification, prevention and management of delirium involving multiprofessionals such as medical, pharmacy, social services, occupational therapy and nursing, from the preoperative assessment stage through to discharge to primary care.
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The Delirium Steering Group adopted toolkits for risk stratification and management of delirium from pre-operative assessment through to admission and discharge. Steering Group meetings involved medical team, anaesthetist & pre-operative assessment team, pharmacist, occupational therapist, physiotherapist, nursing, support staff and social services who embedded the initiative within their teams in a collective leadership approach(4).
The Steering Group promoted a staff educational programme delivered by occupational therapy, pharmacy and medical team and increasing move towards case-based discussions, highlighting pain and benzodiazepine prescribing as risk factors.
Small scale audit cycles were repeated by medical staff January to December 2017.
Areas audited included if delirium risk stratification was assessed at pre-operative assessment stage, use of delirium risk sticker, referral rates by nursing to multiprofessional team for those who developed delirium, and benzodiazepine prescribing.
Patients undergoing orthopaedic surgery, particularly over 65years old benefited from better detection, prevention and management of delirium. Benefits of optimising delirium prevention and management include reduced Length of Stay, increased likelihood of discharge to usual place of residence after surgery as opposed to nursing home, reduced morbidity and mortality associated with delirium.
Average inpatient Length of Stay reduced from 4 days (2016) to 3 days (2017). This will bring inevitable efficiency savings as well as improving waiting list figures.
Delirium reporting increased from 1% baseline to 7% and then 12%, indicating improved identification and risk stratification over 12 months and highlighting delirium as the most common, significant complication with major joint surgery.
Average Length of Stay reduced from 4 days (2016) to 3 days (2017) partly attributable to improved risk stratification and management of delirium.
Risk stratification of delirium at pre-operative assessment led to individualised tailored consent and percentage patients at pre-operative assessment stage with delirium risk factors completed increased from 43 to 100% following promotion of the toolkit.
Nursing staff at ward multidisciplinary morning safety brief highlighted inpatients at risk or who had developed delirium and physiotherapists who are the first to mobilise patients postoperatively reported signs of delirium promptly. The multidisciplinary team embraced an approach to ensure individuals at risk of delirium had glasses & working hearing aids available during consultations as appropriate. Uptake of a new delirium 'risk sticker' developed by the Steering Group to identify 'at risk' or delirious patients increased.
Referrals by nursing to clinical pharmacist for medicines review in delirium increased from 0 to 100% and 100% referrals to occupational therapist for functional cognitive assessment in patients diagnosed with delirium. Clinical pharmacists reviewed pain management, benzodiazepine prescribing and communicated to GP changes to patient's medicines due to delirium.
A culture of referring all patients with delirium to social services for assessment was reinforced following baseline of 66%. Baseline benzopdiazepine prescribing was 75%, prompting a service agreement to avoid prescription of new benzodiazepines pre- or intra-operatively in those at risk.
A holistic, multicomponent approach in line with NICE quality standard on delirium(1) was established. Educational programmes, pre-operative assessment and ward-based initiatives highlighted awareness and management of delirium, bringing improved patient experience and inevitable efficiencies.
Shared leadership in and across multidisciplinary teams(4) enabled a culture shift in highlighting delirium as the most common, significant complication of major joint surgery and optimising management.
