POSTOPED: improving surveillance of postoperative delirium in a Scottish tertiary hospital

Delirium is the most common postoperative complication among patients over the age of 65 years. It is associated with increased morbidity and is a significant financial cost to healthcare systems. We aimed to improve the detection of delirium on the surgical wards of a tertiary surgical centre. This would take the form of completion of 4AT assessments (the 4 AT test for delirium, on admission and 1 day postoperatively). Prior to this project, the 4AT was in use in the surgical admission clerking paperwork for over 65 s, however, 4AT assessments were not routinely performed as part of day 1 postoperative assessment. By introducing routine postoperative assessment and reinforcing the importance of admission assessment, we hoped to allow for objective comparisons to be made about patients cognitive state and thereafter improve delirium identification. After a baseline snapshot data collection period, we conducted five (Plan, Do, Study, Act) cycles following which repeat snapshot data were collected. Improvement strategies included ‘tea-trolley’ teaching sessions, adhesive 4AT pro-forma, targeted accompaniment of specialty ward rounds with reminders to complete 4AT assessments and working with nursing staff to promote awareness of delirium among permanent non-rotating healthcare professionals. For the admission 4ATs, completion improved from a baseline of 74.1%–90.5% in cycle 5. Completion of postoperative 4AT assessments rose from 14.8% at baseline to 47.6% in cycle 5. We were able to improve the use of a delirium screening tool, (the 4AT) among the postoperative elderly population in this centre via the use of regular teaching sessions, targeted interventions on ward rounds as well working with non-rotating staff. Further improvements could be made by widening access to delirium champion programmes and including delirium as an outcome measure of national surgical audits such as the National Emergency Laparotomy Audit.