Think DeliriumScottish Delirium Association Pathway Overview &

Sharing Good Practice

Linda WolffMike Hendrix, NHS Forth Valley

Experience in Forth valley orthopoedic unit

Linda Wolff Mike Hendrix

Improving detection and Management of delirium in hip fracture

Outline

• Where are we now?• Where do we want to be?• How are we trying to get there?

Why Bother?

• National Priority• Delirium present in up to 60% patients over 65

with hip fracture • 3rd busiest ortho unit in Scotland• 380 hip fracture patients/ year• Pressure on beds• Staffing challenges

Delirium Outcomes

• Delirium present in up to 60% patients• Length of stay x 3• 40% mortality• High morbidity• Stress

Patients and carers say…

• Said he was being difficult• Said she has dementia

• They didn’t explain• Took her food away• Too much medication• I was so worried

Where do we want to be?

Reliable recognition and management of delirium in patients with hip fracture

How are we trying to get there?

• Steering group• Questionnaires- staff• Patient stories

• Identification of delirium• Develop management protocol

Protocol

• AMT 10• CAM

• Medical • Pain Management• Nursing• Discharge

Tests of change

Training

• All nursing staff

• Hospital Delirium Study Days

• Presentations to ortho surgeons

AMT 10

• Who will do it ?• Junior docs, staff nurse, ANPs• Audit• Flow chart• Screen saver

Think Delirium!

Untreated delirium can increase length of stay

up to 3 times

Think Delirium!

Any one of these can cause delirium:

• Infection• Fracture• Pain• Mental stress• Constipation• Dehydration• Low oxygen levels• Morphine

How are we doing?

Delirium Bundle

CAM Done1L fluid in first 24 hoursAbbey pain scoreDi-hydrocodeine prescribedUp to sit within 24 hoursDelirium documented Discharge letter

All or nothing

Bundle data July 201250 % had AMT, 83% <9/1030% had CAM 60% fluid >1L No Abbey Pain scores100% analgesia compliance60% up to sit in 24 hoursNO documentation in letter

Sprint Audit 2013 - 24 pts

• 66% AMT10• 62% of those had AMT <9 • 9/10 had a CAM performed• 33% of those CAM +ve• AWI challenges

Successes

• Improved cognitive assessment• Improved staff knowledge• More consistent pain management• Increased documentation of delirium• Introduction of butterfly scheme• Carer’s letter to CE• Mike feel free to add…

Challenges

• Cognitive assessment / detection• Delirium Bundle just starting• AWI irregularities• Engage all medical staff• Evaluation LOS, complaints, questionnaires,

discharge documentation