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

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.