Impact of a delirium prevention project among older hospitalized patients who underwent orthopedic surgery: a retrospective cohort study

Evaluation of the effects of a team-based systematic prevention and management program for postoperative orthopedic older patients: A retrospective cohort study

Aim

This study aimed to evaluate a team-based systematic prevention and management program for delirium (a multicomponent intervention addressing potentially modifiable risk factors based on the DELirium Team Approach [DELTA]) in older patients undergoing orthopedic surgery within a real-world clinical setting. The DELTA program was initiated at our hospital in January 2019.

Methods

A retrospective before-after study was conducted during a preintervention period (January 1, 2017 to December 31, 2018) and a postintervention period (January 1, 2020 to December 31, 2021) at orthopedic wards of an advanced acute care hospital in Japan. A total of 787 inpatients were evaluated before the preintervention period, and 833 inpatients were evaluated after the postintervention period.

Results

After the DELTA program's implementation, a significant decrease in benzodiazepine receptor agonist prescriptions (odds ratio [OR], 0.39; 95% confidence interval [CI], 0.29-0.53) and an increase in prescriptions of either melatonin receptor agonists or dual orexin receptor antagonists (OR, 3.83; 95% CI, 2.49-5.88) were observed. However, no significant difference was observed in the incidence of falls, self-extubation, or required level of medical and nursing care, including risky behavior and inability to follow medical or care instructions following the intervention, despite a reduction in the length of hospital stay and institutionalization.

Conclusion

Implementing the DELTA program for older patients undergoing orthopedic surgery contributed to optimizing the prescription of hypnotics; however, the impact on other patient outcomes, such as falls, self-extubation, and required level of medical and nursing care was limited.

Enhancing delirium assessment and management through nursing education interventions: A scoping review

AIM/OBJECTIVE

The purpose of this scoping review was to explore the characteristics and outcomes of education interventions for nurses focused on delirium assessment and management.

BACKGROUND

Delirium is a prevalent acute and reversible neuropsychiatric syndrome in hospitalized patients. Delirium can cause cognitive, psychiatric and physical impairments and result in prolonged hospital stay, increased risk of readmission and elevated morbidity and mortality rates. Nurses play an essential role in managing delirium. There is a lack of understanding of the existing nursing educational interventions on delirium management.

DESIGN

The study was a scoping review.

METHODS

In this scoping review, we used Arksey and O'Malley's (2005) scoping review framework. We searched articles published between 2019 and 2023 in Academic Search Premier, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and MEDLINE using the following CINAHL/MeSH suggested subject terms: "delirium" in conjunction with "education" "intervention" and "nurse", "nurses" or "nursing." Studies on improving nursing knowledge and practices regarding delirium were included while those focusing on nursing students were excluded. Initial screening involved evaluating article titles and abstracts for relevance from 164 identified articles, followed by a full-text review of 42 articles. Finally, 17 articles were selected for comprehensive analysis. We extracted relevant information from each article and charted the findings in an evidence table.

RESULTS

The 17 selected articles showcased a variety of interventions used to educate nursing staff, such as workshops, simulations, group discussions, online modules and one-on-one coaching. Educational interventions primarily focused on delirium definition, risk factors, assessment and management. These educational interventions enhanced nurses' perception of delirium, boosting their confidence and knowledge in managing delirium. These interventions also led to increased compliance with delirium assessment and management protocols, which ultimately resulted in improved documentation accuracy and patient outcomes.

CONCLUSIONS

Findings from this scoping review suggest that nursing administration need to provide support and education for delirium prevention and management to enhance nursing staff confidence and competence in assessing and managing delirium. The use of interactive educational techniques has demonstrated profound benefits in schema development, expertize promotion and critical thinking. These findings have significant implications for future research, including the identification of essential nursing competencies for educational interventions and the assessment of long-term knowledge retention and its application in nursing practice.

Impact of nursing interventions on discharge disposition in patients with postoperative delirium

PURPOSE

To identify patient characteristics and perioperative factors associated with non-home patient discharges and the impact of current delirium nursing interventions on discharge disposition, especially non-home dispositions.

METHODS

A retrospective pilot chart review was conducted using electronic health records from five networked hospitals in the Mountain West region of the US. The sample comprised 75 randomly selected patients aged 65 or older who screened positive for delirium during hospitalization. Relationships between patient characteristics, nursing interventions, and discharge dispositions were analyzed using chi-square tests and logistic regression.

RESULTS

Most participants (69.3%) were discharged to non-home facilities. Delayed urinary catheter removal was a significant nursing intervention factor. Patients with delayed urinary catheter removal were at increased risk of being discharged to a non-home setting compared with those with early urinary catheter removal (aOR: 14.11, P = .010). Preoperative hypoalbuminemia and surgery durations exceeding 60 minutes were associated with non-home dispositions.

CONCLUSION

Delayed urinary catheter removal, surgery duration greater than 1 hour, and preoperative hypoalbuminemia increased the likelihood of non-home discharge placement for older adults who experience postoperative delirium.

Predicting postoperative delirium after hip arthroplasty for elderly patients using machine learning

BACKGROUND

Postoperative delirium (POD) is a common and severe complication in elderly hip-arthroplasty patients.

AIM

This study aims to develop and validate a machine learning (ML) model that determines essential features related to POD and predicts POD for elderly hip-arthroplasty patients.

METHODS

The electronic record data of elderly patients who received hip-arthroplasty surgery between January 2017 and April 2021 were enrolled as the dataset. The Confusion Assessment Method (CAM) was administered to the patients during their perioperative period. The feature section method was employed as a filter to determine leading features. The classical machine learning algorithms were trained in cross-validation processing, and the model with the best performance was built in predicting the POD. Metrics of the area under the curve (AUC), accuracy (ACC), sensitivity, specificity, and F1-score were calculated to evaluate the predictive performance.

RESULTS

476 Arthroplasty elderly patients with general anesthesia were included in this study, and the final model combined feature selection method mutual information (MI) and linear binary classifier using logistic regression (LR) achieved an encouraging performance (AUC = 0.94, ACC = 0.88, sensitivity = 0.85, specificity = 0.90, F1-score = 0.87) on a balanced test dataset.

CONCLUSION

The model could predict POD with satisfying accuracy and reveal important features of suffering POD such as age, Cystatin C, GFR, CHE, CRP, LDH, monocyte count, history of mental illness or psychotropic drug use and intraoperative blood loss. Proper preoperative interventions for these factors could reduce the incidence of POD among elderly patients.

Implementing a Delirium Risk Stratification Tool and Rounds to Identify and Prevent Delirium in Hospitalized Older Adults

BACKGROUND

Up to 40% of delirium cases are preventable, and early identification is key to improve patient outcomes.

PURPOSE

To implement and evaluate a multidisciplinary delirium intervention program.

INTERVENTION

The delirium intervention program targeted patients at high risk for delirium and included patient and nurse education, risk stratification, multidisciplinary rounds, a nonpharmacological intervention bundle, and a treatment order set.

RESULTS

After implementation, there was a reduction in length of stay of 6.3 days ( P = .01), a 24% decrease in disposition to a skilled nursing facility ( P = .05), and increased detection of delirium by nurses.

CONCLUSION

Positive patient outcomes were achieved by employing a multifactorial approach for delirium identification, prevention, and management. The components of this quality improvement project provide guidance to hospitals seeking to develop a delirium intervention program.

A systematic review of strategies for preventing delirium in patients undergoing vascular surgery

OBJECTIVES

Elderly patients undergoing vascular surgery are at risk of developing postoperative delirium, which is associated with a high mortality. Delirium prevention is difficult and is investigated in surgical patients from various specialisms, but little is known about delirium prevention in vascular surgery. For this reason we performed a systematic review on strategies for delirium prevention in patients undergoing elective surgery for peripheral arterial disease or for an aneurysm of the abdominal aorta.

METHODS

This systematic review included studies describing strategies for preventing delirium in patients undergoing elective surgery for peripheral arterial disease or for an aneurysm of the abdominal aorta. The search was conducted using the keywords 'vascular surgery', 'prevention' and 'delirium', and was last run on October 21st, 2021 in the electronic databases Pubmed, MEDLINE, Embase, Web of Science, the Cochrane library and Emcare. Risk of bias was assessed using the Cochrane Risk of Bias tool for randomized controlled trials and the ROBINS-1 tool for observational studies.

RESULTS

Four studies including 565 patients were included in the systematic review. A significant decrease in the incidence of delirium was reported by a study investigating the effect of comprehensive geriatric assessments within patients undergoing surgery for an aneurysm of the abdominal aorta or lower limb bypass surgery (24% in the control group versus 11% in the intervention group, p = 0.018), and in the total group of a study evaluating the effect of outpatient clinic multimodal prehabilitation for patients with an aneurysm of the abdominal aorta (11.7% in the control group versus 8.2% in the intervention group, p = 0.043, OR = 0.56). A non-significant decrease in delirium incidence was described for patients receiving a multidisciplinary quality improvement at the vascular surgical ward (21.4% in the control group versus 14.6% in the intervention group, p = 0.17). The study concerning the impact of the type of anaesthesia on delirium in eleven older vascular surgical patients, of which three developed delirium, did not differentiate between the different types of anaesthesia the patients received.

CONCLUSION

Despite the high and continuous increasing incidence of delirium in the growing elderly vascular population, little is known about effective preventive strategies. An approach to address multiple risk factors simultaneously seems to be promising in delirium prevention, whether through multimodal prehabilitation or comprehensive geriatric assessments. Several strategies including prehabilitation programs have been proven to be successful in other types of surgery and more research is required to evaluate effective preventive strategies and prehabilitation programs in vascular surgical patients.

Perioperative Multicomponent Interdisciplinary Program Reduces Delirium Incidence in Elderly Patients With Hip Fracture

BACKGROUND

Delirium is common in elderly patients with hip fracture. Although several multicomponent care pathways have been developed, few nurse-led perioperative multicomponent programs have been evaluated.

AIMS

The current study aimed to evaluate the effect of a nurse-led perioperative multicomponent interdisciplinary program in preventing postoperative delirium in elderly patients with hip fracture.

METHOD

The participants in the usual care group were recruited from March 2012 to February 2013, and these in the experimental group were recruited from May 2013 to June 2014. The participants in the usual care group (n = 174) received usual medical and nursing care from admission to hospital discharge and the participants in the experimental group (n = 192) received the nurse-led perioperative multicomponent interdisciplinary intervention. The STROBE checklist was used to report this study.

RESULTS

There were no statistical differences between the two cohorts in terms of the baseline data such as gender, age, fracture type, and so on. The experimental group had a lower incidence of delirium and postoperative hypoxia than the usual care group. No statistical differences in terms of delirium severity, delirium duration, and mean hospitalization length were observed.

CONCLUSIONS

The nurse-led perioperative multicomponent interdisciplinary program described in the current study is feasible and effective in reducing the incidence of postoperative delirium in elderly patients with hip fracture.

Clinical Frailty Scale, K-FRAIL questionnaire, and clinical outcomes in an acute hospitalist unit in Korea

BACKGROUND/AIMS

Frailty increases the risks of in-hospital adverse events such as delirium, falls, and functional decline in older adults. We assessed the feasibility and clinical relevance of frailty status in Korean older inpatients using the Clinical Frailty Scale (CFS) and Korean version of the Fatigue, Resistance, Ambulation, Illnesses, & Loss of Weight scale (K-FRAIL) questionnaires.

METHODS

Frailty status was measured using the Korean-translated version of the CFS and K-FRAIL questionnaire within 3 days from admission in 144 consecutive patients aged 60 years or older. The correlation between CFS and K-FRAIL score was assessed. The criterion validity of CFS was assessed using receiver operating characteristic analysis. As outcomes, delirium, bedsore, length of stay (LOS), in-hospital mortality, and unplanned 30-day readmission were measured by reviewing medical records.

RESULTS

The mean age of the study population was 70.1 years (range, 60 to 91), and 75 (52.1%) were men. By linear regression analysis, CFS and K-FRAIL were positively correlated (B = 0.72, p < 0.001). A CFS cutoff of ≥ 5 maximized sensitivity + specificity to classify frailty using K-FRAIL as a reference (C-index = 0.893). Higher frailty burden by both CFS and K-FRAIL was associated with higher LOS and bedsores. Unplanned readmission and in-hospital mortality were associated with higher CFS score but not with K-FRAIL score, after adjusting for age, gender, polypharmacy, and multimorbidity.

CONCLUSION

Frailty status by CFS was associated with LOS, bedsores, unplanned readmission, and in-hospital mortality. CFS can be used to screen high-risk patients who may benefit from geriatric interventions and discharge planning in acutely hospitalized older adults.

Evaluation of the effectiveness of delirium prevention care protocol for the patients with hip fracture: A randomised controlled study

AIMS AND OBJECTIVES

This study aimed to investigate the effectiveness of a delirium prevention care protocol on pain, functional status, sleep quality and delirium prevention in patients with hip fractures.

BACKGROUND

The development of delirium following hip fracture is common among older patients. According to the National Institute for Health and Care Excellence, 30% of delirium cases are preventable. The prevention of delirium, a multifactorial syndrome, can be achieved through a multicomponent care protocol that targets specific risk factors for delirium.

DESIGN

A randomised controlled study was conducted according to the CONSORT 2010 guidelines. The Clinical Trial Registry number is NCT04188795.

METHODS

A total of 84 patients were assigned to two groups by block randomisation. The intervention group (n = 41) received nursing care according to a protocol and the control group (n = 43) received standard nursing care. Study data were collected using the demographic information form, the Confusion Assessment Method-Intensive Care Unit (CAM-ICU), the Barthel Index, the Mini Nutritional Assessment-short form and the Richards-Campbell Sleep Questionnaire (RCSQ). The pain of the patients was assessed by using a Visual Analog Scale (VAS).

RESULTS

The mean age of the patients was 80.6 years (standard deviation 8.0; range 65.0- 97.5 years), and the percentage of the male patients were 36.3%. No statistically significant differences were found between the groups in terms of pain and functional status in the preoperative period, on the first postoperative day, or in the predischarge period (p > 0.05 for each). The sleep quality of patients in the intervention group was significantly better than in the control group for all three time measurements (p < 0.05 for each). While 15% of patients in the control group developed delirium, no patient in the intervention group developed delirium (x² =6.486, p = 0.026).

CONCLUSION

This study demonstrated that a delirium prevention care protocol may reduce the incidence of delirium and improve sleep quality.

RELEVANCE TO PRACTICE

The study highlighted that nurses can contribute to preventing patients' delirium using nonpharmacologic and independent nursing interventions.

Incidence and associated factors of delirium after orthopedic surgery in elderly patients: a systematic review and meta-analysis

BACKGROUND

A total of 4.5-41.2% of orthopedic surgery patients experience delirium. Until now, no formal systematic review or meta-analysis was performed to summarize the risk factors of delirium after orthopedic surgery.

AIMS

The present study aimed to comprehensively and quantitatively conclude the risk factors of delirium after orthopedic surgery in elderly patients.

METHODS

A search was applied to Medline, Chinese National Knowledge Infrastructure (CNKI), Embase, and Cochrane central database (all up to February 2020). All studies on the risk factors of delirium after orthopedic surgery in elderly patients without language restriction were reviewed, and qualities of included studies were assessed using the Newcastle-Ottawa Scale. Data were pooled and a meta-analysis was completed.

RESULTS

A total of 15 studies altogether included 10,053 patients with orthopedic surgery, 825 cases of delirium occurred after surgery, suggesting the accumulated incidence of 8.2%. Results of meta-analyses showed that age > 70 years (odds ratio (OR) 3.78, 95% confidence interval (CI) 2.97-4.80), advanced age (standardized mean difference 0.82, 95% CI 0.54-1.09), male sex (OR 1.78, 95% CI 1.13-2.79), medical comorbidities (OR 2.18, 95% CI 1.23-3.88), malnutrition (OR 3.10, 95% CI 2.19-4.38), preoperative and postoperative haemoglobin (SMD - 0.37, 95% CI - 0.54 to - 0.19; SMD - 0.33, 95% CI - 0.55 to - 0.11), postoperative sodium (SMD - 0.52, 95% CI - 0.74 to - 0.29) and longer hospitalization after surgery (SMD 0.27, 95% CI 0.11-0.43), hearing impairment (OR 2.78, 95% CI 1.98-3.90), multiple medications (OR 1.36, 95% CI 1.21-1.52), psychotic drugs(OR 4.27, 95% CI 1.37-13.24), morphine (OR 1.97, 95% CI 1.11-3.51), cognitive impairment (OR 2.72, 95% CI 1.96-3.78), length of stay (SMD 0.26, 95% CI 0.14-0.39) and hip surgery (OR 1.63, 95% CI 1.08-2.48) were more likely to sustain delirium after hip surgery in elderly patients. ASA I and II was less likely to develop delirium after orthopedic surgery (OR 0.52, 95% CI 0.34-0.79).

CONCLUSIONS

Related prophylaxis strategies should be implemented in the elderly involved with above-mentioned risk factors to prevent delirium after orthopedic surgery.

Near-Infrared Spectroscopy Monitoring in Cardiac and Noncardiac Surgery: Pairwise and Network Meta-Analyses

Goal-directed therapy based on brain-oxygen saturation (bSo2) is controversial and hotly debated. While meta-analyses of aggregated data have shown no clinical benefit for brain near-infrared spectroscopy (NIRS)-based interventions after cardiac surgery, no network meta-analyses involving both major cardiac and noncardiac procedures have yet been undertaken. Randomized controlled trials involving NIRS monitoring in both major cardiac and noncardiac surgery were included. Aggregate-level data summary estimates of critical outcomes (postoperative cognitive decline (POCD)/postoperative delirium (POD), acute kidney injury, cardiovascular events, bleeding/need for transfusion, and postoperative mortality) were obtained. NIRS was only associated with protection against POCD/POD in cardiac surgery patients (pooled odds ratio (OR)/95% confidence interval (CI)/I2/number of studies (n): 0.34/0.14-0.85/75%/7), although a favorable effect was observed in the analysis, including both cardiac and noncardiac procedures. However, the benefit of the use of NIRS monitoring was undetectable in Bayesian network meta-analysis, although maintaining bSo2 > 80% of the baseline appeared to have the most pronounced impact. Evidence was imprecise regarding acute kidney injury, cardiovascular events, bleeding/need for transfusion, and postoperative mortality. There is evidence that brain NIRS-based algorithms are effective in preventing POCD/POD in cardiac surgery, but not in major noncardiac surgery. However, the specific target bSo2 threshold has yet to be determined.