Think Delirium: A Quality Improvement Project

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E McIntyre1; ESY Lau1, J Jones1; C Veitch1
Countess of Chester Hospital NHS Foundation Trust
Clinical Quality
CQ - Clinical Effectiveness

Abstract

Introduction

Delirium affects up to 50% of older patients (aged over 65 years) in hospital and is associated with serious consequences including greater morbidity and mortality, longer hospital stays with consequent hospital acquired complications, and an increased likelihood of hospital readmission. Early recognition prompting effective management is critical in improving outcomes for patients with delirium. 

Methods 

This QIP was conducted amongst Foundation Year 1 doctors (FY1) working across all wards in a busy district general hospital to improve knowledge of delirium through educational interventions covering definitions, classification, assessment tools, management, predisposing factors, and prognosis. Baseline knowledge was assessed using a multiple-choice questionnaire with re-assessment following a face-to-face teaching presentation, and electronic poster. A follow-up survey assessing participant's perceptions toward delirium management was also conducted.  

Results 

Prior to intervention, an average of 25% of FY1 doctors selected the correct answer in assessment. This rose to 86% post-presentation and remained at 83% following circulation of the poster. Breakdown of results demonstrated a marked improvement of 59% of clinicians being able to define, and 95% able to classify delirium. An improvement of 51% was noted in the knowledge of assessment tools and a notable 94% in knowledge of pre-disposing factors. Baseline knowledge of prognosis was excellent at 89% and a 2% reduction was noted following interventions. 81% of clinicians felt their knowledge of delirium strongly improved following interventions and 60% strongly agreed to feeling more confident in managing delirium.

Conclusion 

The implementation of two distinct educational interventions, through plan-do-study-act cycles, were successful in improving knowledge of delirium.  Targeted teaching significantly improved knowledge and understanding, and a follow-up educational poster was a useful tool in promoting knowledge retention and reinforcement.  These findings support the strategy of implementing focussed delirium education early in medical training as an avenue to improve patient care.

Comments

Do you have any ideas how this shortfall in knowledge could be proactively addressed in a way that would be tangible to new foundation doctors?

Submitted by iainwilkinson1_13125 on

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Since this project was started, we now include specific teaching sessions on Delirium, with other important Geriatric Medicine topics in the Foundation teaching. This was newly added to their curriculum and so I would expect other Trusts to be providing similar sessions. There are also specific CBL sessions for out 4th Year medical students on Delirium, that the Care of the Elderly department at the Countess of Chester Hospital are directly involved with. 

Submitted by caroline.veitch on

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As a Geriatricians, we are somewhat biased, but yes. We feel strongly, that aside from those working specifically in pediatrics and obstetrics, topics relating to Geriatric Medicine will be important to know about in every other medical specialty. Having an understanding of Delirium, how it is recognised and then managed is important, and for this reason it has now been included in the Foundation curriculum. I would encourage all Trusts to provide educational sessions in this area, particularly for our junior colleagues, as they are on the front line and will often be the first assessor for these patients. 

Submitted by caroline.veitch on

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This is a really important area, especially for emphasising the importance of delirium early recognition and the simple but effective measures we should be including in our regular ward reviews of these frail patients. Can this be embedded into hospital-wide induction for the FY trainees? I feel that some of the frailty-related issues like delirium should be included early and emphasised emphatically in early teaching, to set a good foundation for their work.

Submitted by finbarr15549 on

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Absolutely! Our rationale for targeting FY1 doctors primarily surrounded the fact that 1. they form a significant proportion of the medical front line, and may be the first to encounter a patient with Delirium, and 2. our hypothesis that early educational intervention in postgraduate training may be most beneficial in regards to patient outcomes, by equipping trainees with the tools to identify/manage delirium prior to entering higher specialty training pathways.

We have worked with the local foundation programme team to include this and other care of the elderly topics into the foundation curriculum, to ensure this important teaching is delivered to all, and to new rotating doctors. 

This looks like a great project! Would you be happy to share your teaching resources with local hospitals?

Submitted by laura_jane.bray on

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Excellent piece of work! As an FY2 myself, I strongly believe that delirium is not taught well enough at medical schools and we need to ensure that awareness and understanding is there for newly graduated doctors, who are often one of few doctors present on the wards during out of hours, etc. Projects like this will hopefully highlight recognition, causes and management of delirium.

Submitted by arun.joshi3@nhs.net on

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Very important piece of work, current FY1 and have felt that delirium is hard to wrap my head around. No doubt your resources are very informative!

Submitted by rebecca.crudge… on

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Well done in completing the QIP. This a relatively straightforward QIP idea that could inspire other members to undertake similar projects. How will you ensure that the effects of the intervention are sustainable, especially considering the regular rotation of resident doctors every few months?

Submitted by Kweieng.tan_24283 on

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Interesting question thanks. So far our Care of the Elderly team have worked with our local foundation programme team to include medicine for the elderly teaching, including this topic, into the FY1 teaching curriculum.. We think this is a useful application and ensures delivery of this important topic to the FY1 cohort. It may be interesting to revisit again in FY2 for consolidation and to see how perceptions change with added clinical experience. 

Great project to put delirium in the spotlight for FY1s - so common but often forgotten. Also, a fab idea to provide content 4 weeks later, and to complete the survey 4 weeks later,

Submitted by jwilliams3610@… on

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