Short summary

In 2020 Odense University Hospital (OUH), decided to constitute a strategic benchmark; 'Handling Delirium' through a large scale implementation of a multidisciplinary guideline. The guideline contained guidance on handling delirium with aspects of risk factors, identification (CAM-score), communication with relatives, non-pharmacological and pharmacological interventions.

Rationale

Introduction The presentations of older people in-hospital either as an acute presentation or hospitalized in a ward are often a complex mixture of acute and chronic medical problems; adverse drug effects and issues related to functional, social, and cognitive impairment combined with unmet care needs (Ellis et al., 2022). However, the most common complication is delirium (Inouye et al., 2014, Fong et al., 2015). Delirium is an acute decline in cognitive functioning and a serious and potentially fatal disorder, which affects 50 % of older people (+65 years) in-hospital (Fong et al., 2015, Inouye et al., 2014, Mattison, 2020). In Europe, delirium is estimated to cost healthcare systems more than 172 billion Euros (Inouye et al., 2014). Delirium does not only represent a major health expense, but also has multiple consequences affecting the patient, relatives and health care professionals (HCPs) (Schmitt et al., 2019, Mossello et al., 2020, Rekvad et al., 2021, Thomas et al., 2021).

Background Delirium is an acute change in mental status and is characterized by inattention and disturbance in cognition (Fong et al., 2015). It develops over a short period of time with a fluctuating course of symptoms (Fong et al., 2015, Hshieh et al., 2020, Swarbrick and Partridge, 2022). All individuals are at risk of delirium, although some will be at higher risk; those with more vulnerabilities such as comorbidity, advanced age, exposures to other stressors, infection or certain medications (Mattison, 2020).

The pathophysiology of delirium is not fully understood (Bennett, 2019, Mattison, 2020, SST A, 2021) but it is often a sign of a serious underlying condition afflicting the patient (Hshieh et al., 2020, Han et al., 2017). Being affected by delirium is correlated with longer hospital stay, increased complications in-hospital, institutionalization, an incremental worsening of 6-month functional and cognitive outcomes and a higher 6-months mortality (Dharmarajan et al., 2017, Han et al., 2017, Mosk et al., 2017).

Delirium appears with a widely variable symptom presentation, which cause the condition is often missed and underdiagnosed (Fong et al., 2009, Mosk et al., 2017, SST A, 2021). Therefore, a formal assessment is needed (Grossmann et al., 2014).

If the condition is addressed from a patient and family member perspective, it is described as an innervating lack of control and feelings of powerlessness, anxiety, and paranoia (Schmitt et al., 2019, Boehm et al., 2021, Rekvad et al., 2021). Many patients report strong feelings of guilt and shame after the resolution of a delirium episode, due to some patients found themselves verbally or physically aggressive or having delusions during the delirium episode (Rosa et al., 2019, Ellis et al., 2022). In the same way, family members report feelings of being unprepared to handle the delirium, which also leads to a feeling of loss and powerlessness. Seeing their love ones changing in cognition is hard to cope with (Rekvad et al., 2021, Schmitt et al., 2019, Boehm et al., 2021). The same powerlessness is found from the HCPs perspective. HCPs experience difficulties in the care relationship as the patients is described complicated to cooperate with due to the risk of aggressive periods and delusions (Schmitt et al., 2019, Rekvad et al., 2021).

Therefore, delirium is associated with a high level of burden and an increased risk for burn-out for HCPs (Mossello et al., 2020). Beside the psychological burden, this patient group can increase the workload as the patient will present time consuming care needs due to the cognitive decline(Thomas et al., 2021). Therefore, many strong arguments, from different perspectives, point at the importance of HCPs ability to handle delirium in clinical practice (Piotrowicz et al., 2018, Travers et al., 2018, Thomas et al., 2021). This can be reached by education (Travers et al., 2018, Mossello et al., 2020, Grossmann et al., 2014).

When HCPs are educated to identify the trigger causes of delirium and early identification, prevention and treatment, it could ensure an earlier response for patients in risk of - or in active - delirium (Bennett, 2019, Mossello et al., 2020). Previous studies have shown that up to one-third of delirium cases are preventable and prevention is the most effective strategy for minimizing the occurrence of delirium and its adverse outcomes (Fong et al., 2009, Bennett, 2019, Grossmann et al., 2014).

Despite the educational recommendation, delirium still remains unrecognized (Inouye et al., 2014) and unfortunately a lack of knowledge and poor understanding of the benefits of the early recognition and treatment of delirium amongst the HCPs in-hospital remains (Travers et al., 2018, Bennett, 2019, Thomas et al., 2021). Studies highlight the positive effect of using a clinical screening tool as a part of the education of the HCPs, like the evidence-based tool; Confusion Assessment Method (CAM)(Berube et al., 2020, Grossmann et al., 2014, Ma et al., 2021). If HCPs are educated to manage and use the CAM score, a higher rate of patients will be identified (Grossmann et al., 2014, Piotrowicz et al., 2018). The risk of further development of delirium may be reduced if adequate interventions are initiated. Implementation of multicomponent non-pharmacological interventions reduce the odds of developing delirium and effectively treat the delirious condition (Bennett, 2019, SST A, 2021, Casanova Querol et al., 2022, Berube et al., 2020, Dharmarajan et al., 2017, Patel et al., 2014, Mudge et al., 2022). Especially, when the implementation of the non-pharmacological interventions is multidisciplinary, there is a positive effect in both eliminating the powerless feeling for the patient, relatives and HCPs and in reducing the risk of delirium (Heim et al., 2019, Rekvad et al., 2021).

However, multidisciplinary guidelines in delirium prevention have been limited to specific wards, such as intensive care unit, emergency departments or medical wards. Nevertheless, it is recommended to implement guideline programs more widely to align in-hospital interventions (Patel et al., 2014, Soo Rui Ting et al., 2021, Mudge et al., 2022). No clinical guideline to assess delirium was found efficiently implemented in the Danish health care system (15).

In 2020 Odense University Hospital (OUH), decided to constitute a strategic benchmark; 'Handling Delirium' through a large scale implementation of a multidisciplinary guideline. The guideline contained guidance on handling delirium with aspects of risk factors, identification (CAM-score), communication with relatives, non-pharmacological and pharmacological interventions. All HCPs caring or treating patients aged + 65 years were included in a 1-year implementation period (2021-2022). In total, this included 41 wards at two geographical localities under the parent organization OUH. All of the 41 wards were included and received in total 211 teaching sessions including tools and techniques to handle delirium.

Objective This PhD study aims to evaluate and explore the effect and data from the implementation process of the multidisciplinary guideline 'Handling Delirium' at OUH (2020-2022). This will be done by: 1) A literature review of previous interventions targeting delirium in-hospital and its implementation and evaluation strategies, 2) Examining if the delirium diagnoses registered in the electronic medical records of older hospitalized patients reflect the true incidence of delirium and if the multidisciplinary guideline affects the number of delirium diagnoses registered, and 3) Explore barriers and possibilities of implementing the multidisciplinary guideline across the 41 wards focusing on HCPs perspectives.

Description of the cohort

All HCPs caring or treating patients aged + 65 years were included in a 1-year implementation period (2021-2022). In total, this included 41 wards at two geographical localities under the parent organization OUH. All of the 41 wards were included and received in total 211 teaching sessions including tools and techniques to handle delirium.