Reducing the use of lorazepam and increasing adherence to the delirium guideline using Epic® digital search functions.

Introduction:

Despite it's known deliriogenic properties, and contrary to trust guidelines, lorazepam is often used first line in the management of delirium at Manchester Royal Infirmary without a documented rationale. This project aims to improve adherence to trust delirium guidance - reducing the use of lorazepam in the pharmacological management of delirium and improving compliance with non-pharmacological elements.

Methods:

Case identification was carried out using the hospital's Electronic Patient Record (EPR) system, Epic®. A report was created to display patients with a coded diagnosis of "Delirium", however, following assessment of the data quality it became clear that this report was failing to capture the expected patient population. A further report was created which displayed patients who had been prescribed medications used in delirium (Lorazepam, Haloperidol, Quetiapine, Olanzapine); data was collected over a 4-week period and patients who had been prescribed one of these medications for an alternative indication were excluded.

Once baseline data had been collected, a programme of education took place. This involved the distribution of posters which outlined key nursing steps, summarised the non-pharmacological and pharmacological management of delirium – highlighting haloperidol as first line and signposting to the full guideline. Data was then recollected using the same dashboard.

Results:

There was a significant drop in the prescription of lorazepam by 70%. An average of 8.75 patients received pharmacological management for their delirium per week at baseline. This reduced to 2.6 patients per week following poster distribution. There was no corresponding increase in the use of haloperidol, with lorazepam remaining the first choice for the small number receiving pharmacological management. There was a significant increase in the use of non-pharmacological tools including behaviour charts.

Next steps include implementing a bespoke order set for prescribing in delirium with similar information to the distributed posters and linked to the delirium guidance.