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Management of Delirium: A Clinical Governance Approach

By Kulh, Mary Ann; Mumford, Virginia A. et al. | Australian Health Review, May 2005 | Go to article overview

Management of Delirium: A Clinical Governance Approach


Kulh, Mary Ann, Mumford, Virginia A., Sorensen, Roslyn, Budge, Marc M., Australian Health Review


Abstract

This study assessed the management of delirium in the Acute Care of the Elderly unit (ACE) at a tertiary referral hospital as a case study of the application of clinical governance principles. The environment was found to be supportive of ongoing clinical governance activities, both in clinical organisation of work processes and orientation of management. However, patient involvement, dissemination and use of clinical pathways, performance measurement and feedback, and maintaining stability of care are areas requiring further development. Although there is a clinical governance strategy in place at the policy level, this has not always filtered through to the level of clinical work.

Aust Health Rev 2005: 29(2): 246-252

ACUTE CONFUSIONAL STATE (ACS) or delirium is a disturbance of consciousness and attention, which may be the consequence of an acute medical condition or the result of medication use. Older adults are particularly vulnerable due to reduced compensatory mechanisms, both cognitive and physical, and the increased risk of side-effects from medications. ACS is associated with poor outcomes including increased mortality1 prolonged length of stay, and increased risk of institutionalisation.2

From a quality perspective, the development of ACS in hospital is a marker of iatrogenic complications and inadequate hospital care.3 There is increasing evidence for the management of delirium in a multidisciplinary context, yet the infrastructure to support such clinical care is not always available. Furthermore, it is unclear how to practically assess the deficiencies in organisational management hindering delivery of quality care.

Setting

The Canberra Hospital (TCH) is a 500-bed acute care teaching hospital and a clinical unit of two university medical schools. The Acute Care of the Elderly (ACE) unit provides acute medical assessment and management services to the aged population of surrounding ACT and NSW health services.

Definitions

Clinical governance: the framework adopted by organisations to ensure accountability for the quality care of patients. The framework, for this study, encompasses performance measurement and feedback, systematisation of clinical work (eg, through use of clinical pathways), risk management and patient involvement.

Acute confusional state or delirium: a medical condition, more commonly seen in older adult patients, defined by:

* a disturbance in level of consciousness;

* change in cognition;

* acute onset (hours to days);

* presence of an underlying cause such as a medical condition, medication or substance intoxication, substance withdrawal, or a combination of these (adapted from American Psychiatric Association4).

Study aims

The study aims were:

* To examine the management performance of the ACE unit, with particular reference to management of ACS;

* To determine whether the management of ACS in the ACE unit accords with good clinical governance.

Apart from its reflection on hospital care, we selected ACS as the focus of the survey because we wished to assess the recently introduced ACS clinical pathway. The pathway outlines locally agreed best practice for the treatment of ACS and was developed by a multidisciplinary team. We assessed the impact of the clinical pathway on the management of these patients to determine whether the pathway was being used as intended or whether it needed modification. This study is not an appraisal on the clinical appropriateness of the ACS protocol.

Study methodology

The study consisted of three components:

* Medical record audit;

* Survey of the clinicians' perceptions of the organisation of clinical work (Clinician Self-Assessment Survey), administered by questionnaire;

* Survey of managers' perspectives on the organisational structure (Assessment of the Organisational Environment), administered by interview.

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