Improving Hospital Delirium Screening and Documentation.

BACKGROUND: Appropriate delirium screening and documentation are important for hospitalized patients to ensure positive patient outcomes and patient safety. A preliminary process review at Mayo Clinic in Rochester, Minnesota, identified low adherence (25.9%) to delirium screening and documentation requirements.

PURPOSE: The aim of this quality improvement (QI) project was to identify gaps in delirium screening and documentation, determine possible causes of these gaps, and design interventions to help improve the completion of required delirium screening and documentation over one year without adversely affecting other required nursing assessments. The target of the project was an improvement in the rate of screening documentation of at least 50%.

METHODS: After Mayo Clinic's preliminary process review identified low adherence to delirium screening and documentation requirements, a multidisciplinary workgroup was convened, and a QI project following Six Sigma methods was implemented between May 2022 and April 2023 (the study period). Review of electronic health records (EHRs) and an informal survey of nurses and personal care assistants (enhanced by interviews and shadowing) facilitated fishbone analysis and creation of an impact-effort grid showing the relative difficulty and impact of possible interventions. An automated data-monitoring dashboard for the EHR was developed, and the Brief Confusion Assessment Method (bCAM) documentation in the EHR was restructured and introduced (first intervention). Nurse educational modules were amended to be consistent across practice areas, and a best-practice advisory (BPA) was created to bridge communication between nurses (RNs) and clinicians (physicians, NPs, and physician assistants). Delirium screening was added to the reminder list of required shift documentation in February 2023 (second intervention). A counterbalance measure, pressure injury risk, was chosen as a proxy for other required nursing assessments to show any unintentional downturn in other staff performance.

RESULTS: After the bCAM redesign was introduced on June 1, 2022, delirium screening documentation decreased to 17.4% by June 30, but increased to 19.4% by July 31. After the RN educational module was implemented on July 1, delirium screening documentation increased further, to 20.7% by August, but dipped again to 13.7% by January 2023. After delirium screening was included in the required shift documentation reminder list in February 2023, delirium screening documentation significantly increased, from the baseline rate of 25.9% in May 2022 to 42.8% in March 2023 (P < 0.001) and to 47.7% in April 2023 (P < 0.001). The BPA was also associated with an increase in clinician capture of delirium diagnoses in the EHR of 47%. The rates of pressure injury risk assessment remained the same throughout the study period with only minor fluctuations.

CONCLUSIONS: In this QI project, the addition of delirium screening to shift documentation was associated with a greater than 50% increase in screening documentation, suggesting improved nurse-clinician communication. Introduction of the BPA was also associated with increased clinician capture of delirium diagnoses in the EHR. Implementing these intervention changes may improve patient outcomes and safety.