A quality improvement project addressing the underreporting of delirium in hip fracture patients

Naoko Onizuka, Fernando A. Huyke-Hernández, Myriam A. Roby, Tom F. Martell, Rachael M. Scislow, Sarah C. Jones, Andrew Olson, Nicole James, Julie A. Switzer

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1 Scopus citations


Introduction: After discovering a low incidence of delirium for hip fracture patients at our institution, we evaluated if this was due to underreporting and, if so, where process errors occurred. Methods: Hip fracture patients aged ≥60 with a diagnosis of delirium were identified. Chart-Based Delirium Identification Instrument (CHART-DEL) identified missed diagnoses of delirium. Process maps were created based off staff interviews and observations. Results: The incidence of delirium was 15.3% (N = 176). Within a random sample (n = 98), 15 patients (15.5%) were diagnosed, while 20 (24.7%) went undiagnosed despite evidence of delirium. Including missed diagnoses, delirium prevalence was higher in the sample compared to all patients (35.7% vs 15.3%, p < 0.001). Most missed diagnoses were due to failure in identifying delirium (60%) or failure in documenting/coding diagnosis (20%). The prevalence of baseline cognitive impairment was higher in undiagnosed delirium patients versus correctly diagnosed patients (80% vs 20%, p = 0.001). Conclusions: Our institution significantly underreports delirium among hip fracture patients mainly due to; (1) failure to identify delirium by the clinical staff, and (2) failure to document/code diagnosis despite correct identification. Baseline cognitive impairment can render delirium diagnosis challenging. These serve as targets for quality improvement and hip fracture care enhancement.

Original languageEnglish (US)
Article number100974
Pages (from-to)100974
JournalInternational Journal of Orthopaedic and Trauma Nursing
StatePublished - Nov 2022

Bibliographical note

Funding Information:
We would like to acknowledge the orthopaedic nursing team and additional staff at Park Nicollet Methodist Hospital for their participation in process interviews.

Publisher Copyright:
© 2022 Elsevier Ltd

PubMed: MeSH publication types

  • Journal Article


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