Improving delirium assessment in gastroenterology inpatients: a two-cycle quality improvement project in a district hospital

 Introduction

Delirium prevalence is approximately 15-20% in medical inpatients and potentially higher within gastroenterology inpatients due to increased prevalence of liver disease. Delirium causes longer admissions, worse morbidity and mortality outcomes and distress to patients, families and staff.

The National Institute for Health and Care Excellence (NICE) recommends that inpatients are assessed for delirium within 24 hours of admission. Assessment on admission was outside the remit of this project but there was an opportunity to improve assessment from the point of admission to a gastroenterology ward.

Methods

The Plan-Do-Study-Act model was utilised, with interventions targeted at gastroenterology resident doctors, who were consulted in each planning stage.

The primary outcome measure was the percentage of inpatients receiving a delirium assessment within 24 hours of admission to either the Emergency Department (ED) or gastroenterology ward. Process and balancing measures were also evaluated.

A baseline audit demonstrated inadequate delirium assessment within 24 hours (42%). Feedback from resident doctors indicated that limited knowledge and forgetting to assess during ward rounds were major contributors. Intervention 1 was an education session. Intervention 2 was a pilot ward round document mandating delirium assessment. Outcomes were re-audited after each cycle.

Results

Self-rated confidence improved after intervention 1; however the primary outcome worsened (42%-> 24%), likely due to poor attendance. Participants also requested a clearer “step-by-step” guide. Intervention 2 achieved 100% in the primary outcome. Feedback from participants focussed on increased workload, although suggested that the benefits outweighed the inconvenience.

Conclusions

The teaching session will be repeated for the next cohort across multiple sessions to increase reach. The pilot document will be expanded locally and, if successful, across the healthcare trust, with additional project leaders recruited from other hospitals. This should increase assessments rates, further research should determine whether this improves patient outcomes.