Improving quality of delirium care in a general medical service with established interdisciplinary care: a controlled trial.

BACKGROUND: Clinical practice guidelines have been developed to improve screening, prevention and management of delirium.

AIMS: To implement delirium guidelines in general medical patients to reduce incidence and duration of delirium and improve outcomes in delirious patients.

METHODS: Implementation was led by a multidisciplinary team of clinicians and project staff on one medical ward. Evaluation was undertaken as a controlled trial in patients aged 65 years or older with/at risk of delirium, compared with a control medical ward. Interventions included risk screening, delirium detection, multidisciplinary education, ward modifications including a four-bed delirium bay, behaviour and medication protocols, and use of nursing assistant and volunteers. Primary outcome measures were incidence and duration of delirium; secondary outcomes were length of stay, mortality, falls and discharge destination in delirious subgroup. Process measures included ward moves, use of neuroleptics, allied health review and delirium bay use.

RESULTS: Of 206 consenting older medical patients, 22% were delirious at admission and 44% were at risk. No incident cases of delirium were identified. In the delirious subgroup, significantly fewer intervention participants were discharged with persistent delirium (32% vs 71%, P = 0.016), with trends to reduced inpatient mortality (0% vs 18.5%, P = 0.07) and falls (11% vs 22%, P = 0.16), at the expense of a longer medical ward stay (16 days vs 8 days, P = 0.01).

CONCLUSIONS: Low incidence of new delirium may reflect the established interdisciplinary care environment. Improved outcomes in the delirious group are encouraging although implementation was costly, including increased length of acute ward stay.