1. Think Delirium Scottish Delirium Association Pathway Overview & Sharing Good Practice Linda Wolff Mike Hendrix, NHS Forth Valley

2. Improving detection and Management of delirium in hip fracture
Experience in Forth valley orthopoedic unit
Linda Wolff Mike Hendrix

3. Outline Where are we now? Where do we want to be?
How are we trying to get there?

4. Why Bother? National Priority
Delirium present in up to 60% patients over 65 with hip fracture
3rd busiest ortho unit in Scotland
380 hip fracture patients/ year
Pressure on beds
Staffing challenges

5. Delirium Outcomes Delirium present in up to 60% patients
Length of stay x 3
40% mortality
High morbidity
Stress

6. Patients and carers say…
Said he was being difficult
Said she has dementia
They didn’t explain
Took her food away
Too much medication
I was so worried

7. Where do we want to be?
Reliable recognition and management of delirium in patients with hip fracture

8. How are we trying to get there?
Steering group
Questionnaires- staff
Patient stories
Identification of delirium
Develop management protocol

10. Protocol
AMT 10
CAM
Medical
Pain Management
Nursing
Discharge

11. Tests of change

12. Training All nursing staff Hospital Delirium Study Days
Presentations to ortho surgeons

14. AMT 10 Who will do it ? Junior docs, staff nurse, ANPs Audit
Flow chart
Screen saver

15. Think Delirium!

16. Untreated delirium can increase length of stay up to 3 times

17. Think Delirium!

18. Any one of these can cause delirium:
Infection
Fracture
Pain
Mental stress
Constipation
Dehydration
Low oxygen levels
Morphine

19. How are we doing?

21. Delirium Bundle CAM Done 1L fluid in first 24 hours Abbey pain score
Di-hydrocodeine prescribed
Up to sit within 24 hours
Delirium documented Discharge letter
All or nothing

22. Bundle data July 2012
50 % had AMT, 83% <9/10 30% had CAM 60% fluid >1L No Abbey Pain scores 100% analgesia compliance 60% up to sit in 24 hours NO documentation in letter

23. Sprint Audit 2013 - 24 pts 66% AMT10 62% of those had AMT <9
9/10 had a CAM performed
33% of those CAM +ve
AWI challenges

25. Successes Improved cognitive assessment Improved staff knowledge
More consistent pain management
Increased documentation of delirium
Introduction of butterfly scheme
Carer’s letter to CE
Mike feel free to add…

27. Challenges Cognitive assessment / detection
Delirium Bundle just starting
AWI irregularities
Engage all medical staff
Evaluation LOS, complaints, questionnaires, discharge documentation