Think Delirium
Scottish Delirium Association Pathway Overview &
Sharing Good Practice
Linda Wolff
Mike Hendrix, NHS Forth Valley
Improving detection and
Management of delirium in hip
fracture
Experience in Forth valley
orthopoedic unit
Linda Wolff Mike Hendrix
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
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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
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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
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Medical
Pain Management
Nursing
Discharge
Tests of change
Training
• All nursing staff
• Hospital Delirium Study Days
• Presentations to ortho surgeons
AMT 10
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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:
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Infection
Fracture
Pain
Mental stress
Constipation
Dehydration
Low oxygen levels
Morphine
How are we doing?
Delirium Bundle
CAM Done
1L fluid in first 24 hours
Abbey pain score
Di-hydrocodeine prescribed
Up to sit within 24 hours
Delirium documented Discharge letter
All or nothing
Bundle data July 2012
50 % had AMT, 83% <9/10
30% had CAM
60% fluid >1L
No Abbey Pain scores
100% analgesia compliance
60% up to sit in 24 hours
NO documentation in letter
Sprint Audit 2013 - 24 pts
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66% AMT10
62% of those had AMT <9
9/10 had a CAM performed
33% of those CAM +ve
AWI challenges
Successes
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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
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Cognitive assessment / detection
Delirium Bundle just starting
AWI irregularities
Engage all medical staff
Evaluation LOS, complaints, questionnaires,
discharge documentation