Is your hospital delirium-sensitive?
Delirium detection brings many benefits
These include triggering local management pathways, enabling clear communication of the diagnosis to patients and carers, a coherent approach from staff, and better follow-up information (Wilson et al., 2020).
There is also some evidence that early detection and treatment can reduce the severity and duration of delirium (Pitkala et al., 2006). This is not only good for patients. It likely also reduces financial costs (Caplan et al., 2020), a major issue given that delirium affects at least 1 in 7 people in hospital.
A key hospital performance metric is delirium detection
So it follows that a key performance metric for any hospital is how much delirium is detected. However we know from many studies that sadly we are still underdetecting delirium in hospitals across the globe (for example, van Velthuijsen et al., 2018).
Another measure of performance is the rates of delirium coded in hospital discharge summaries. This kind of data can be obtained from individual hospitals, but also from larger public and institutional databases.
Here is an example of national coding data. This shows increasing rates of delirium coding in discharge summaries between 2012 and 2020 in data from all Scottish hospitals. The increases are most marked in older age groups (source: Public Health Scotland (Scottish Government)).
Underpinning processes: episodic and monitoring tests
Most delirium in hospitals is present on admission, though a substantial minority of delirium also arises after admission. A delirium-sensitive hospital needs therefore to have effective processes to detect delirium at the front door (ED, medical admissions, etc.), and also to pick up delirium arising after admission. The first process can be called episodic, and the second process monitoring.
A case study: delirium detection at the front door in two Scottish hospitals
From hospitals and systems with increasing or even already good delirium detection, what can we learn?
Some local data from Edinburgh focusing on front-door delirium detection has shown some improvements:
This happened through a combined approach of years of education and implementation of a pragmatic detection tool - the 4AT (Tieges et al., 2020). Delirium care was pushed up the agenda very strongly in Scotland in 2012 with a combined national effort from the Scottish Delirium Association and Healthcare Improvement Scotland. This led to policy changes and widespread education efforts in hospitals and through multiple national events. Overall this led to an improved awareness of delirium in healthcare staff, with tangible increases in use of the term delirium in day to day care.
The publication of national guidelines on delirium by the Scottish Intercollegiate Guidelines Network in 2019 has further bolstered the profile of delirium in our healthcare system.
What can we do to make hospitals more delirium-sensitive?
It has become clear over the last few years that improving delirium care is a multifaceted challenge. We need to combine many elements to make progress, and to make improvements stick:
I would say that there is particular benefit in focusing (initially at least) on delirium detection. This means (a) having some kind of episodic test implemented at the front door and used at other key points in the patient journey for example in transitions of care or post-operatively, and (b) a monitoring process to pick up delirium arising after admission in higher risk patients.
Alongside the introduction of workable, effective processes for delirium detection it is also necessary to have education that covers not only the basics of delirium and the tools being used but also the crucial aspects of attitudes and ownership (Teodorczuk et al., 2013).
To support tool implementation and the educational work, setting clear standards and gaining institutional support for introducing these is vital.
Finally, what is also needed is measurement. We not only need to introduce good tools, education, and standards, but also look at real-world performance. What are your tool completion rates? What level of delirium are the tools detecting, and do they reflect the real rates of delirium? Only by closely measuring what we are doing can we tell if our hospitals are truly delirium-sensitive.
References
Caplan GA, et al. The financial and social costs of delirium. Eur Geriatr Med. 2020 Feb;11(1):105-112. doi: 10.1007/s41999-019-00257-2.
Pitkälä KH, et al. Multicomponent geriatric intervention for elderly inpatients with delirium: a randomized, controlled trial. J Gerontol A Biol Sci Med Sci. 2006 Feb;61(2):176-81. doi: 10.1093/gerona/61.2.176.
Teodorczuk A, et al. Reconceptualizing models of delirium education: findings of a Grounded Theory study. Int Psychogeriatr. 2013 Apr;25(4):645-55. doi: 10.1017/S1041610212002074.
Tieges Z, et al. Diagnostic accuracy of the 4AT for delirium detection in older adults: systematic review and meta-analysis. Age Ageing. 2020 Nov 11:afaa224. doi: 10.1093/ageing/afaa224.
van Velthuijsen EL, et al. Zwakhalen SMG, Mulder WJ, Verhey FRJ, Kempen GIJM. Detection and management of hyperactive and hypoactive delirium in older patients during hospitalization: a retrospective cohort study evaluating daily practice. Int J Geriatr Psychiatry. 2018 Nov;33(11):1521-1529. doi: 10.1002/gps.4690.
Wilson JE, et al. Delirium. Nat Rev Dis Primers. 2020 Nov 12;6(1):90. doi: 10.1038/s41572-020-00223-4.