A quality improvement project addressing the underreporting of delirium in hip fracture patients

Int J Orthop Trauma Nurs. 2022 Nov:47:100974. doi: 10.1016/j.ijotn.2022.100974. Epub 2022 Oct 12.

Abstract

Introduction: After discovering a low incidence of delirium for hip fracture patients at our institution, we evaluated if this was due to underreporting and, if so, where process errors occurred.

Methods: Hip fracture patients aged ≥60 with a diagnosis of delirium were identified. Chart-Based Delirium Identification Instrument (CHART-DEL) identified missed diagnoses of delirium. Process maps were created based off staff interviews and observations.

Results: The incidence of delirium was 15.3% (N = 176). Within a random sample (n = 98), 15 patients (15.5%) were diagnosed, while 20 (24.7%) went undiagnosed despite evidence of delirium. Including missed diagnoses, delirium prevalence was higher in the sample compared to all patients (35.7% vs 15.3%, p < 0.001). Most missed diagnoses were due to failure in identifying delirium (60%) or failure in documenting/coding diagnosis (20%). The prevalence of baseline cognitive impairment was higher in undiagnosed delirium patients versus correctly diagnosed patients (80% vs 20%, p = 0.001).

Conclusions: Our institution significantly underreports delirium among hip fracture patients mainly due to; (1) failure to identify delirium by the clinical staff, and (2) failure to document/code diagnosis despite correct identification. Baseline cognitive impairment can render delirium diagnosis challenging. These serve as targets for quality improvement and hip fracture care enhancement.

MeSH terms

  • Delirium* / diagnosis
  • Delirium* / epidemiology
  • Hip Fractures* / complications
  • Hip Fractures* / psychology
  • Humans
  • Incidence
  • Quality Improvement
  • Risk Factors