Enhancing Delirium Documentation at the Hospital-Community Interface

Introduction

Delirium is common in older inpatients and associated with cognitive decline, underlying dementia, and mortality. NICE recommends that current or resolved delirium diagnosis is communicated to general practitioners (GPs) upon discharge. A 2021–22 quality improvement project at Lister Hospital improved the delirium assessments consistently to over 95% across the Trust. However, this study found that only 25% of delirium cases were documented in discharge letters. This gap poses significant risks to patient safety, as unresolved delirium may be overlooked, and underlying dementia missed. This project aimed to improve documentation of delirium diagnoses, resolution status, and follow-up advice in discharge letters.

Method 
Electronic patient records under Unplanned Care at Lister Hospital were retrospectively analysed for patients aged ≥65 years with a recorded 4AT score ≥4.

Cycle 1 targeted resident doctors with formal teaching and ward-based education on delirium assessment and documentation practices. Wards with high delirium rates were prioritised.

Cycle 2 expanded to the multidisciplinary team (MDT), with teaching delivered at a Trust Clinical Governance meeting, Nursing Manager Huddle, and alongside Dementia Champions during Dementia Awareness Week. Posters and patient information leaflets were distributed.  

Results

Following Cycle 1, 4AT reassessment on discharge rose from 5% to 13%. Delirium documentation in discharge letters improved significantly from 54% to 76%. Discharge advice to GPs recommending referral to memory clinics more than quadrupled from 5% to 22%. After Cycle 2, 4AT reassessment reached 16% and follow-up advice 25%. Delirium documentation dipped to 61% but remained above baseline.

Conclusion

Sustained improvement is achievable through targeted educational interventions reinforced across the MDT. Resident-focused teaching yields rapid improvements which are now embedded into the mandatory teaching program locally, but sustainable change requires wider MDT engagement. Long-term progress may necessitate systemic changes, such as integrating delirium prompts into electronic discharge templates. Future work could assess downstream outcomes, including GP follow-up, community referrals, dementia diagnostic yield, and re-admissions.