Problem

This project was started after a newly established service within NHS Tayside, the Surgical Acute Frailty Team (SAFT), had noted a considerable number of their referrals were for support with management of delirium in postoperative patients. This was despite the availability of management bundles such as the TIME1 bundle and guidelines by the National Institute for Health and Care Excellence.2 3 It was apparent that knowledge of investigation and management of delirium was lacking.

This project was undertaken at Ninewells Hospital, a tertiary care hospital with five inpatient acute surgical wards. NHS Tayside covers a population of approximately 400 000 people,4 and in 2018–2019, it performed 7019 emergency operations across all surgical specialties.5 At the inception of this project, the 4AT,6 a screening tool for delirium, had been embedded into the acute admission clerking documentation for elderly patients (ie, aged ≥65 years of age), but there had been no systematic follow-up of its use, and whether patients had been assessed for delirium postoperatively. This is despite British Geriatrics Society (BGS) guidance that recommends daily 4ATs for surgical inpatients over the age of 65.7

Preintervention snapshot data showed that 74.1% of elderly inpatients underwent 4AT assessments on arrival to the acute surgical admission unit; of these 15% were identified as delirious (4AT score ≥4). Only 14.8% of all elderly patients went on to receive postoperative assessments for delirium, of which 50% of these assessments identified delirium. The inference we drew was that assessments were being done when attention was brought to medical staff that a patient was ‘confused,’ which in discussions with ward staff proved to be the case.

This behaviour is reactive in nature, rather than the proactive approach that professional guidelines recommend.7 This approach risks missing many patients with delirium, and some literature estimates that 60%–66% of delirium diagnoses are missed,8 9 due partly to hypoactive forms of the syndrome. We wished to change the reactive process that seemed to be happening on the wards, with a proactive one.

From conversations with staff, it was recognised that several barriers existed which prevented this. Namely that, 4AT assessments would take too long on busy surgical ward rounds and that staff were simply not aware that such guidance existed (not surprising given the cited guidance from the BGS was first published in 2021). We aimed to change these views and create an environment where assessment was easier to perform, and in this way improve compliance to perioperative care guidelines. When such monitoring was achieved, further projects could focus on specific management of delirium itself, via bundles such as the TIME bundle1 and our own POSTOPED bundle (see online supplemental figure 5).

We collected data for this project on the inpatient ‘postoperative’ surgical wards, however, some interventions were implemented on the admission ‘preoperative’ wards (see online supplemental figure 4) both settings during their rotations within the department. This project ran from April 2021 to December 2021.

Our SMART aims were.

1. Increase the proportion of elderly (those aged ≥65 years) operative patients who had an admission 4AT assessment from 74.1% to 95% by December 2021.

2. Increase the proportion of elderly operative patients who had a day 1 postoperative 4AT assessment from 14.8% to 50% by December 2021.

These two aims were formed to produce a situation where an individual patient would have a ‘baseline’ cognitive assessment on admission and a ‘repeat’ cognitive assessment in the postoperative period. Enabling objective comparison for an individual patient across their hospital stay, in an environment where multiple ward changes are common early in the patient journey.

Background

Delirium is an acute fluctuant confusional state composed of a disturbance in attention and awareness that is a change from the baseline cognition.9–12 The criteria for delirium make clear that for such a diagnosis, there must be evidence that the presentation is of a ‘direct physiological consequence’ of another medical condition or state. As a syndromic classification, delirium has a broad definition, and many precipitating factors of ‘physiological consequence’ have been identified, yet it is usually multifactorial.13 Several of these physiological antecedents are frequently encountered in the surgical environment.

Delirium is the most common surgical complication among those aged above 65 years of age.14 15 In 2018, 25% of all hip fracture repair patients in England met the diagnostic criteria for delirium.16 Such a diagnosis adversely affects patients; a study of Canadian postoperative elderly patients found that those that met the diagnostic criteria for delirium spent on average 7.4 days more in hospital than those without, at a cost of $C1 million.17 Delirium contributes significantly to mortality.18 A US Medicare claimants study19 found that it was associated with increased mortality risk relative to controls up to 12 months post index presentation. Though commonly associated with an acute cognitive deficit, delirium appears to be influential in subsequent long-term cognitive decline, with a pathological mechanism distinct from dementia and age related cognitive impairment.20 21

The TIME1 bundle was developed for use within the AMU (Acute Medical Unit) department at North Middlesex Hospital as both a surveillance and management strategy for delirium. Using an improvement strategy of staff education and practical aids for the ward environment, they had notable success in increasing the use of the 4AT from 40% to 61% within one Plan, Do, Study, Act (PDSA) cycle. Since then, the TIME bundle has seen support among care of the elderly departments across the UK and has been taught at medical schools. Seeing the proliferation of this project, we sought to adapt their methods to the surgical environment and attempting some of their further recommendations, in particular the use of frailty link nurses. Adaption of delirium education materials to environments other than medical wards has precedent, with a quality improvement project involving the Greater Manchester Critical Care Network showing improvement in the use of screening tools.22

Measurement

Data for this quality improvement project were collected in a series of six ‘snapshots,’ totalling 149 patients, between March 2021 and November 2021. The first snapshot, ‘baseline,’ was taken on 26 March 2021. In each intervention cycle, a planning meeting would occur, actions would thereafter be taken, and then approximately a month following said action a data snapshot of current progress to our aims would be taken.

Data collection snapshots were collected on 22 June (cycle 1), 30 July (cycle 2), 4 September (cycle 3), 18 October (cycle 4) and 25 November 2021 (cycle 5).

Design

The main intervention was the use of ‘tea-trolley’ teaching sessions (teaching slides are found in online supplemental figure 6). Recognising the time pressures of medical and nursing staff to attend formalised teaching sessions, the SAFT conducted short 5–10 min teaching sessions within doctors’ rooms on the surgical floor wards in which we were trying to promote change along with providing snacks and drinks as an incentive. At the launch of the project, we conducted a similar session to senior surgical colleagues at a grand rounds ‘clinical effectiveness meeting’ in April 2021.

With presentations in smaller groups for shorter periods, we hoped to strengthen audience engagement over more didactic lecture theatre-based methods. Such sessions would also act as reminders for the resources made available to staff, such as the THINK delirium toolkit,24 25 patient information leaflets, delirium management guidelines and in later cycles, the use of 4AT assessment stickers. By improving the interactive nature of our education, we reasoned that this would promote increased compliance to our audit standard and lead to improved delirium surveillance.

From the third snapshot cycle onwards, we introduced adhesive 4AT tools. Evaluating previous interventions seen for peripheral venous catheter bundles26 and surgical handovers, we felt that the use of detailed documentation paperwork could prove obstructive to our aims of promoting a quick, easy and effective screening tool. We, therefore, supplied all intervention wards with 4AT assessment ‘checkbox like’ stickers (online supplemental figures 2 and 3), enabling clear and speedy documentation of delirium screening. These were placed on medical notes trolleys on the wards to enable ease of access on ward rounds.

Additional interventions included accompanying specialty ward rounds, engagement with frailty link nurses and highlighting in departmental meetings to surgical colleagues the prevalence and importance of postoperative delirium. We noted a few issues with our planned interventions at the outset of this study. First was the issue of engagement with all ward staff. We noted that despite our best efforts, it would not always be possible to reach all ward staff on our teaching days. Therefore, we aimed to complete sessions in the period after lunch, at the time of the ‘back’ shift starting. Consequently, our tea-trolley sessions would be to wards at the highest staffing levels during the day in a period where much of the ward work had been completed and staff had had their lunch breaks. This we reasoned would optimise engagement with, and reach of, our sessions. We also widened our education activities in later intervention cycles to non-rotating staff such as nurses.

Second, the issue of whether to use a ‘bundle form’, à la checklist manifesto culture.27 A trend in the production of quality improvement project checklists and forms was noted at the commencement of this project. Considering the NHS (National Health Service) paper-lite strategy, and being keen to streamline our approach to assessment, we deliberately did not produce a bundle-like A4 sheet form for staff to fill. While this may initially make improvement harder to implement without objective, clear and deliberate forms to take note of, we deemed this a more sustainable design, as by implementing a culture of assessment independent of material resources, surveillance would occur when said forms were not available, and thus survive the duration of the quality improvement project.

The SAFT consists of a consultant geriatrician, a specialty doctor, one advanced nurse practitioner and one clinical fellow. Our intervention sessions involved the use of resources that were easily replicable, consistent in their messaging and could be delivered by all levels of the multidisciplinary team. SAFT consists of permanent, non-rotating staff, who have regular contact with the intervention wards via regular ward rounds and reviews. We, thus, deemed our interventions to be sustainable.

Strategy

At the outset of this project, we spoke informally to ward staff, and SAFT discussed their experiences with referrals to their team for delirium advice in design meetings. We took a baseline snapshot set in March 2021. Following this, we conducted five PDSA cycles.

Lessons and limitations

Our findings suggest that a combination of regular education and training, involvement of the multidisciplinary team as well as targeted intervention in areas of high prevalence of our problem of interest was effective in producing progress towards the project aims.

As stated in our design, we wished to promote a delirium surveillance culture. Our changes, and their effects, would not be rooted in material resources but rather in the altered awareness of professionals to a common postoperative complication. Improvements were seen despite, rather than due to, the introduction of 4AT assessment stickers on the wards, where uptake was virtually absent. In crowded ward environments full of paper forms and limited space to place them, we could not account for instances where on-ward staff overrode our strategic placing of resources.

We did not survey medical or nursing staff on their use of the 4AT adhesive tools, this could have been something we completed after the first cycle of their introduction to further understand their reception and better use them. We also did not survey those who received teaching via our tea-trolley sessions to see the reach of our teaching sessions, which would have enabled objective assessment of efficacy of the sessions and the number of staff reached.

Later in the project, we focused our efforts on vascular patients, as they were a plurality within the snapshot cohorts. The vascular surgery department has smaller number of medical staff but a significantly comorbid and frail patient population. SAFT did not have the resources to accompany every surgical ward round, but focusing on the particularly morbid population, dialoguing directly with the small number of medical staff responsible for their care we reasoned we could have a significant impact. This appears to have been the case noting significant incremental increases in compliance to our standard following these interventions. Targeted interventions were, therefore, a particularly effective strategy.

We found a significant reduction in compliance following one of our cycles due in part to the influx of medical staff new to both the NHS and the surgical department. We tried to counter this by including nursing staff in our interventions, with surgical advance nurse practitioners and frailty link nurses who delivered teaching sessions and disseminated reminders to nursing staff. This could be improved on, however. Previously, the Royal College of Nursing ran a CPD (continuing professional development) scheme called ‘delirium champions’28 which educated nurses on recognising delirium in their patients and beginning initial assessment via the 4AT. Future interventions could include reinstitution of such a scheme locally, with accompanying remuneration/portfolio recognition for revalidation purposes. This could help to incentivise uptake as it would avoid such a scheme as being seen as an ‘extracurricular’ process, and instead be one which would be part of one’s normal workload, making it easier to staff to learn and engage with the material within.

Our focus in this project was on surveillance with acute inpatients. We did not assess the efficacy of interventions for our 4AT positive patients. Although we had produced a surgically orientated management strategy in the POSTOPED bundle poster, given that surveillance was so poor postoperatively at the outset of this project, we felt that this would be a step for the future. Once regular monitoring for delirium was in place, we would be better placed to introduce surgically targeted delirium management schemes, and thus be able to follow in separate projects, whether, for example, pain and analgesia had been appropriately reviewed.

Of note is that delirium is an outcome measure in the National Hip Fracture database as a postsurgical complication.16 This project was conducted in a single centre, however, a top-down approach could also be of benefit, as it is noted that the National Emergency Laparotomy Audit does not include delirium or 4AT surveillance as an outcome measure,29 despite the procedure encumbering similar delirium antecedent factors. Such a change could highlight the awareness that delirium needs in the surgical environment. Locally, SAFT collects data on delirium in the frail postoperative patients to review outcomes and to improve care of patients with delirium.

Our approach was labour-intensive and reliant on regular teaching sessions. This could not continue indefinitely. Going forward, such sessions would be conducted 4 monthly for junior medical staff during induction periods with frailty nurses providing sessions for nursing staff at similar intervals. Towards the end of this project, several specialties in this centre were migrating to electronic note platforms (in this case eKORA), where specific types of entry form exist for different clinical encounters (such as uploading of operation notes, admission forms and certification of death). A specific postoperative review form which would require the 4AT to be filled in before submission, was discussed as a possible further intervention once the surgical departments had migrated to this system, as it was felt an electronic system would make completion easier. This migration has not yet occurred.