Post-Operative Delirium Assessment: a Two-Cycle Quality Improvement Project

Introduction 

As an orthogeriatric service caring for patients >60 years who are having operative management for neck of femur fractures, our patients are a high risk group for the development of delirium. The National Hip Fracture Database recommends 4AT by the third day after surgery. Our local guidelines also recommend recording delirium assessment in a standardised EPR entry. This QIP aimed to assess compliance with both national and local guidelines.

Methods

In February 2026, 17 patients aged >60 were admitted to our orthogeriatric service with neck of femur fractures and were managed operatively. We assessed compliance with both national guidelines as well as local guidelines. An intervention was introduced to improve compliance - a flowchart that was emailed to residents and displayed in the doctors' office demonstrating how to use the standardised entry tool. We then completed the second cycle of the audit with patients admitted in April 2026, where 33 patients aged >60 were admitted to our orthogeriatric service.

Results

The first cycle of our audit demonstrated excellent compliance with national guidelines, with 100% of patients having 4AT documented by third day post operatively. This is higher than the national average of 93%. However, we noticed that our compliance with local guidelines was poorer, with 11.8% documented incorrectly. This was the target for our quality improvement. Our second cycle demonstrated improvement in this area, with only 6% documented incorrectly.

Conclusions

Delirium assessment is an important aspect of caring for the older person with a neck of femur fracture. Clear guidance on documentation of delirium assessment in the form of written instructions for EPR use improves compliance with local guidelines. A multi-pronged approach is likely necessary to ensure continued compliance with national and local guidelines, particularly with rotating resident doctors who may not be familiar with the local system.