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Hospital Harm: Delirium

Delirium is a state of confusion that comes on very suddenly and lasts hours to days. It can cause changes in a person’s ability to stay alert, remember, be oriented to time or place, speak or reason clearly.

Topics
  • Hospital harm
  • Patient safety
Audience

  • Point of care provider

  • Quality or safety improvement lead

  • Policy advisor or analyst

Goal

To improve the early detection and reduce the incidence of delirium in at risk hospitalized patients in intensive and general care units through implementation of standardized delirium screening and prevention strategies.

Overview

Healthcare Excellence Canada has developed this Hospital Harm Improvement Resource – a compilation of resources to support patient safety and improvement efforts.

Delirium can be caused by many things including having an infection, recent surgery, various medical conditions, untreated pain, starting, increasing or stopping some medicines, or not eating or sleeping well. Many things can make delirium worse including physical restraints, bed rest, bladder catheters and certain medications (Coalition for Seniors' Mental Health 2017; American Delirium Society 2015).

Delirium is a common problem in hospitalized ICU patients. It is sometimes not recognized or is misdiagnosed as another condition such as dementia or depression. Patients who experience delirium in the hospital (compared to patients without delirium) are more likely to:

  • Stay longer in the hospital and have more hospital associated complications.

  • Experience higher mortality rates in the hospital and up to six to 12 months later.

  • Lose physical function in the hospital and need long-term care after the hospital.

  • Develop dementia or similar types of cognitive impairment even if the delirium clears (American Delirium Society 2015).

Delirium can be prevented. The most important step in delirium management is early recognition and prevention making it an important strategy for quality improvement (Safer Healthcare Now! 2013).

Importance to Patients and Families

Delirium can also be referred to as "sundowning" or "ICU psychosis" (American Delirium Society 2015). It may be frightening to family members who are often more aware of the changes in a family member's mental status than are the care providers. With the proper care, delirium can be prevented or minimized (Safer Healthcare Now!, 2013). Family involvement, particularly in critical care, does not reduce delirium incidence but improves psychological recovery (Black 2011).

Patient Story

Let's Respect

Mr. Graham was admitted to hospital with dysphagia and weight loss. He was very confused and uncooperative, believing that staff were trying to poison him. On admission, Mr. Graham's wife explained that he had Alzheimer's disease and described to staff how he usually presented and what he was able to do for himself. She also advised that he had recently been admitted in a confused state to another hospital. Mr. Graham was in fact in the early stages of dementia and had retained good insight into his problems. To many people, he would not usually have appeared 'confused' because of his good social skills.

Unfortunately, the diagnosis of 'dementia' became dominant in his hospital notes, to the degree that this prevailed over his presenting health problems. Despite the details his wife had given, it was assumed that all of Mr. Graham's confusion was due to his dementia and that this was 'normal' and therefore did not warrant further investigation. Mrs. Graham did not feel that all her husband's confusion was due to his dementia, but staff did not seem to be listening, and so she contacted their mental health liaison nurse. The nurse's assessment revealed that Mr. Graham was suffering from anaemia and she recommended further investigation.

It was found that he had indeed been admitted to another local hospital just two months earlier with the same problem. He had received four units of blood and his delirium improved. Mr. Graham received a further blood transfusion and much of his confusion cleared, but his haemoglobin levels were not maintained, and he continued to lose weight due to his difficulty with swallowing. By now, Mr. Graham had become very quiet and subdued. Further investigations eventually followed, and Mr. Graham was found to have a malignant growth in his oesophagus. He died in hospital two weeks later.

Mr. Graham's case demonstrates the dangers of failing to recognize Delirium in people who have dementia and subsequently denying them the assessment and care they are entitled to.

It also shows the importance of listening to those who know the patient well. The need for improved communication and further training and education for hospital staff is also indicated by this case (Let's Respect 2006).

Clinical and System Reviews, Incident Analyses

Given the broad range of potential causes of Delirium, clinical and system reviews should be conducted to identify potential causes and determine appropriate recommendations.

Occurrences of harm are often complex with many contributing factors. Organizations need to:

  1. Measure and monitor the types and frequency of these occurrences.

  2. Use appropriate analytical methods to understand the contributing factors.

  3. Identify and implement solutions or interventions that are designed to prevent recurrence and reduce risk of harm.

  4. Have mechanisms in place to mitigate consequences of harm when it occurs.

Measures

Vital to quality improvement is measurement, and this applies specifically to implementation of interventions. The chosen measures will help to determine whether an impact is being made (primary outcome), whether the intervention is actually being carried out (process measures), and whether any unintended consequences ensue (balancing measures). In selecting your measures, consider the following:

Whenever possible, use measures you are already collecting for other programs.

Evaluate your choice of measures in terms of the usefulness of the final results and the resources required to obtain them; try to maximize the former while minimizing the latter.

Try to include both process and outcome measures in your measurement scheme.

You may use different measures or modify the measures described below to make them more appropriate and/or useful to your particular setting. However, be aware that modifying measures may limit the comparability of your results to others.

Posting your measure results within your hospital is a great way to keep your teams motivated and aware of progress. Try to include measures that your team will find meaningful and exciting (IHI 2012).

Discharge Abstract Database

Discharge Abstract Database (DAD) Codes included in this clinical category: A05: Delirium

Concept: Temporary disturbance in consciousness with changes in cognition identified during a hospital stay.

Prevention Success Stories

References

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