Duncan Forsyth is Consultant Geriatrician in Cambridge and was a specialist adviser to the Quality Standards Development Group.
On July 24th 2014, NICE published its Delirium Quality Standards to assist health and social care drive-up the quality of delirium management in hospital and care home settings. The standards cover: assessment; prevention; use of antipsychotic medication; communicating the diagnosis; information and support to those who have delirium and their carers. Delirium is probably the commonest complication of hospitalisation in older people and has a high prevalence in those in long-term care.
- Those most at risk of delirium are the core business of all acute hospitals: those aged >65yrs, those with cognitive impairment, the sick, and those with hip fracture. This describes over 60% of the in-patient population!
- There will be those who have developed delirium prior to admission to hospital (prevalent delirium) and those who become delirious after admission (incident delirium).
- Many of those most vulnerable to developing delirium will be living in care homes or may be discharged to a care home.
- NICE Delirium Quality Standards will help any organisation assess their current practice of management and prevention of delirium and help define areas for quality improvement.
- Reducing incidence or duration of delirium can have significant impact on quality of care, length of stay, falls, mortality and institutionalisation rates.
- Statement 1: People newly admitted to hospital or long-term residential care who are at risk of delirium are assessed for recent change in behaviour. This can be linked to the National Dementia CQUIN and is surely not asking much but just that we assess those who present to our services! I see no cost attached to this – it is simply doing our job.
- Statement 2: People newly admitted to hospital or long-term residential care who are at risk of delirium have a multicomponent intervention package to prevent delirium that is tailored to their needs. Well this is simply about the fundamentals of good care; ensuring people are comfortable, hydrated, fed, pain free, etc. It is what I would call good hotel service or simply caring.
- Statement 3: People with delirium in hospital or long-term residential care who are distressed or are a risk to themselves or others are not prescribed antipsychotic medication unless verbal and non-verbal de-escalation techniques are ineffective or inappropriate. It should be relatively simple to audit prescribing of antipsychotics against delirium management guidelines and use this to help educate staff that de-escalation techniques are not mysterious but those that many of then use regularly at home in getting their toddlers ready to go out or to eat or have a bath; or to keep themselves safe in a potentially dangerous environment such a s a pub or club any week-end!
- Statement 4: People with delirium who are discharged from hospital have their diagnosis of delirium communicated to their GP. We can do a lot better – according to national HES data less than 1% of recorded hospital admissions are coded for delirium. The current poor standards of communication miss an opportunity to identify those at risk of future episodes of delirium and the possibility of avoiding this.
- Statement 5: People with delirium in hospital or long-term residential care, and their family members and carers, are given information that explains the condition and describes other people’s experiences of delirium. Delirium is a frightening experience not just for those who witness it but the individual may also have some insight in to their delirious episode and need their behaviour explaining and put in to context. But having written information is not enough – it must be given out and you need a means of recording this.
I encourage you to consider these five quality statements and measure your service against them to help identify where you might improve on the quality of delirium prevention and management. Remember that most older people who suffer from delirium will have a background of dementia. Good dementia and delirium management simultaneously improves care and costs. As my CEO Keith McNeil says: “Good care costs less”.