The effect of a multidisciplinary care bundle on the incidence of delirium after hip fracture surgery: a quality improvement study

Abstract

Summary Delirium is a common complication following hip fracture surgery. We introduced a peri‐operative care bundle that standardised management in the emergency department, operating theatre and ward. This incorporated: use of fascia iliaca blocks; rationalisation of analgesia; avoidance of drugs known to trigger delirium; a regular education program for staff; and continuous auditing of compliance. The study was conducted between June 2017 and December 2018. We recruited 150 patients before (control group) and 150 patients after (care bundle group) the introduction of the care bundle. In patients having surgery for a hip fracture, there was a lower incidence of delirium on the third postoperative day in the care bundle group compared with the control group (33 patients (22%) vs. 49 patients (33%)), respectively; p = 0.04). Patients in the care bundle group had an adjusted OR of 2.2 (95%CI 1.1–4.4) (p = 0.03) for the avoidance of delirium on the third postoperative day. There was no difference between groups for the secondary outcome measures (measured at 30 days postoperatively) including: all‐cause mortality; composite morbidity; institutionalisation; and walking status. During the study period, compliance with elements of the care bundle improved in the emergency department (49 patients (33%) compared with 85 patients (59%); p < 0.001) and anaesthetic department (40 patients (27%) compared with 104 patients (69%); p < 0.001), while orthogeriatrics maintained a high level of compliance (140 patients (93%) compared with 143 patients (95%); p = 0.45). There was a clinically and statistically significant reduction in the incidence of delirium following hip fracture surgery in patients treated with a multidisciplinary care bundle.

Management of delirium within intraoperative settings for older adults with hip fracture: a scoping review

“…Inadequate pain control was highlighted as a potential contributor to risk of delirium development (Chuan et al, 2020; Martocchia et al, 2015; Patel et al, 2018; Poeran et al, 2020; Uysal et al, 2020). However, control of pain with morphine in the post‐operative period was found to triple the risk of developing delirium (Smith et al, 2017).…”

“…However, control of pain with morphine in the post‐operative period was found to triple the risk of developing delirium (Smith et al, 2017). Chuan et al (2020) examined an analgesia bundle of care using femoral nerve blocks aimed at reducing multiple opioid use in particular intravenous morphine which showed reduced incidence of delirium in the intervention group. Unneby et al (2020) hypothesised that providing adequate analgesia via femoral nerve block may reduce the incidence of delirium.…”

Orthogeriatric Anaesthesia

“…The 2012/20 AAGBI guidelines detail the management of common early postoperative complications, including pain, oxygenation, fluid balance and delirium [6]. These are essentially continuations of the primary aims of anaesthesia in the hip fracture population, namely the avoidance of 'ischaemia' through appropriate pain, blood pressure, oxygen, fluid and blood management, so that the consequences of 'ischaemia'-delirium [23], heart pump or rhythm disturbance, acute kidney injury, delay in remobilisation-are avoided.…”

Síndrome confusional agudo en pacientes con fractura de cadera en el área sanitaria de León: buenas prácticas de enfermería = Acute confusional syndrome in patients with hip fracture in the León health care area: good nursing practice

“…En este mismo sentido, es importante señalar como este colectivo presenta mayores estancias hospitalarias y por tanto una mayor consumo y demanda de recursos sanitarios (Instituto Nacional de Estadística, 2019). Es por todo ello, que se hace esencial destacar la importancia de valorar el papel de enfermería dentro del sistema sanitario al aparecer como un elemento clave a la hora de evaluar día tras día a los pacientes hospitalizados, siendo nexo de unión con los facultativos, buscando en todo momento prestar una asistencia individualizada y de carácter multidisciplinar (Chuan et al, 2020) Las fracturas de cadera (FC) o fractura de la extremidad del fémur representan un gravamen a nivel sanitario debido a la alta prevalencia, morbimortalidad y coste económico que suponen al Estado. Se trata de la complicación más grave de la osteoporosis, produciéndose en nuestro país en torno a 50.000-60.000 fracturas anuales (Singer, McLauchlan, Robinson, & Christie, 1998), siendo éstas en un 85 % de los casos producidas en personas de más de 75 años (Dreinhöfer et al, 2018).…”

“…En este sentido, es esencial llevar a cabo una actuación y atención de manera multidisciplinar (Chuan et al, 2020), con una atención individualizada e integral, siendo el personal de enfermería pieza clave en el proceso hospitalario.…”