Surgical Acute Frailty Team, NHS Tayside, Dundee, UK
Surgical Acute Frailty Team, NHS Tayside, Dundee, UK.
BMJ Open Qual. 2023 Mar;12(1). doi: 10.1136/bmjoq-2022-002161.
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.
谵妄是 65 岁以上患者最常见的术后并发症。它与发病率增加有关，也是医疗保健系统的重大经济负担。我们旨在提高三级外科中心外科病房对谵妄的检测能力。这将采取完成 4AT 评估（谵妄的 4AT 测试，入院时和术后 1 天）的形式。在这个项目之前，4AT 已在 65 岁以上患者的外科入院登记文书中使用，但 4AT 评估不作为术后第 1 天评估的常规内容。通过引入常规术后评估并加强入院评估的重要性，我们希望能够对患者的认知状态进行客观比较，从而提高谵妄的识别能力。在基线数据采集期之后，我们进行了五次（计划、执行、研究、行动）循环，然后再次收集快照数据。改进策略包括“茶车”教学课程、粘性 4AT 预填表格、有针对性地陪伴专科病房查房并提醒完成 4AT 评估以及与护理人员合作提高固定非轮转医疗保健专业人员对谵妄的认识。对于入院 4AT，在第 5 个循环中，完成率从基线的 74.1%提高到 90.5%。术后 4AT 评估的完成率从基线的 14.8%上升到第 5 个循环的 47.6%。我们能够通过定期教学课程、在病房查房时进行有针对性的干预以及与非轮转人员合作，提高该中心术后老年人群中使用谵妄筛查工具（4AT）的能力。通过扩大对谵妄拥护者计划的访问权限并将谵妄纳入国家外科审计（如国家紧急剖腹术审计）的结果测量，可以进一步改进。
