Trends in delirium coding rates in older hospital inpatients in England and Scotland:full population data comprising 7.7M patients per year show substantial increases between 2012 and 2020

BackgroundLittle information is available on change in delirium coding rates over time in major healthcare systems. We examined trends in delirium discharge coding rates in older patients in hospital admissions to the National Health Service (NHS) in England and Scotland between 2012 and 2020.MethodsHospital administrative coding data were sourced from NHS Digital England and Public Health Scotland. We examined rates of delirium (F05 from ICD-10) in patients aged ≥70 years in 5 year and ≥90 age bands.ResultsThere were approximately 7,000,000 discharges/year in England and 700,000/year in Scotland. Substantially increased delirium coding was observed for all age bands between 2012/2013 and 2019/2020 (p<0.001, Mann Kendall’s tau). In the ≥90 age band, there was a 4-fold increase between 2012 and 2020.ConclusionDelirium coding rates have shown large increases in the NHS in England and Scotland, likely reflecting several factors including policy initiatives, detection tool implementation and education

Early mobilisation after hip fracture surgery is associated with improved patient outcomes:a systematic review and meta-analysis

Introduction:- The aims of this systematic review and meta-analysis were to determine if after hip fracture surgery 1) early mobilisation is associated with improved clinical outcomes, and if so 2) are benefits directly proportional to how soon after surgery the patient mobilisesMethods:- A PRISMA systematic review was conducted using four databases to identify all studies that compared postoperative early mobilisation with delayed mobilisation in patients after hip fracture surgery. The Critical Appraisal Skills Programme checklist was employed for critical appraisal and evaluation of all studies that met the inclusion criteria. Results:- A total of thirteen studies including 297,435 patients were identified, of which 235,275 patients were mobilised early and 62,160 were mobilised late. Six studies assessed 30- day mortality, of which two also investigated 30-day complication rates. Pooled meta-analysis demonstrated that there were significantly lower 30-day mortality rates (OR 0.35, 95% CI 0.31 - 0.41, p<0.001) and complication rates (OR 0.43, 95% CI 0.36 - 0.51, p<0.001) in patients mobilising early after hip fracture surgery. Five studies investigated length of stay and metaanalysis revealed no difference between groups (mean difference -0.57 days, 95%CI -1.89 - 0.74, p=0.39). Conclusion:- Early mobilisation in hip fracture patients is associated with a reduction in 30-day mortality and complication rates compared to delayed mobilisation, but no difference in length of stay. These findings illustrate that early mobilisation is associated with superior post operative outcomes. However, a direct casual effect remains to be demonstrated, and further work on the factors underlying delayed mobilisation is required

Positive Scores on the 4AT Delirium Assessment Tool at Hospital Admission are Linked to Mortality, Length of Stay, and Home Time:Two-Centre Study of 82,770 Emergency Admissions

BACKGROUND: Studies investigating outcomes of delirium using large-scale routine data are rare. We performed a two-centre study using the 4 ‘A’s Test (4AT) delirium detection tool to analyse relationships between delirium and 30-day mortality, length of stay and home time (days at home in the year following admission). METHODS: The 4AT was performed as part of usual care. Data from emergency admissions in patients ≥65 years in Lothian, UK (n = 43,946) and Salford, UK (n = 38,824) over a period of [Formula: see text] 3 years were analysed using logistic regression models adjusted for age and sex. RESULTS: 4AT completion rates were 77% in Lothian and 49% in Salford. 4AT scores indicating delirium (≥4/12) were present in 18% of patients in Lothian, and 25% of patients in Salford. Thirty-day mortality with 4AT ≥4 was 5.5-fold greater than the 4AT 0/12 group in Lothian (adjusted odds ratio (aOR) 5.53, 95% confidence interval [CI] 4.99–6.13) and 3.4-fold greater in Salford (aOR 3.39, 95% CI 2.98–3.87). Length of stay was more than double in patients with 4AT scores of 1–3/12 (indicating cognitive impairment) or ≥ 4/12 compared with 4AT 0/12. Median home time at 1 year was reduced by 112 days (Lothian) and 61 days (Salford) in the 4AT ≥4 group (P < 0.001). CONCLUSIONS: Scores on the 4AT used at scale in practice are strongly linked with 30-day mortality, length of hospital stay and home time. The findings highlight the need for better understanding of why delirium is linked with poor outcomes and also the need to improve delirium detection and treatment

COVID-19 during the index hospital admission confers a 'double-hit' effect on hip fracture patients and is associated with a two-fold increase in 1-year mortality risk

PURPOSE: The aims were to: (1) determine 1‐year mortality rates for hip fracture patients during the first UK COVID‐19 wave, and (2) assess mortality risk associated with COVID‐19. METHODS: A nationwide multicentre cohort study was conducted of all patients presenting to 17 hospitals in March‐April 2020. Follow‐up data were collected one year after initial hip fracture (‘index’) admission, including: COVID‐19 status, readmissions, mortality, and cause of death. RESULTS: Data were available for 788/833 (94.6%) patients. One‐year mortality was 242/788 (30.7%), and the prevalence of COVID‐19 within 365 days of admission was 142/788 (18.0%). One‐year mortality was higher for patients with COVID‐19 (46.5% vs. 27.2%; p < 0.001), and highest for those COVID‐positive during index admission versus after discharge (54.7% vs. 39.7%; p = 0.025). Anytime COVID‐19 was independently associated with 50% increased mortality risk within a year of injury (HR 1.50, p = 0.006); adjusted mortality risk doubled (HR 2.03, p < 0.001) for patients COVID‐positive during index admission. No independent association was observed between mortality risk and COVID‐19 diagnosed following discharge (HR 1.16, p = 0.462). Most deaths (56/66; 84.8%) in COVID‐positive patients occurred within 30 days of COVID‐19 diagnosis (median 11.0 days). Most cases diagnosed following discharge from the admission hospital occurred in downstream hospitals. CONCLUSION: Almost half the patients that had COVID‐19 within 365 days of fracture had died within one year of injury versus 27.2% of COVID‐negative patients. Only COVID‐19 diagnosed during the index admission was associated independently with an increased likelihood of death, indicating that infection during this time may represent a ‘double‐hit’ insult, and most COVID‐related deaths occurred within 30 days of diagnosis

A comparison of the revised Delirium Rating Scale (DRS–R98) and the Memorial Delirium Assessment Scale (MDAS) in a palliative care cohort with DSM–IV delirium

Objective: Assessment of delirium is performed with a variety of instruments, making comparisons between studies difficult. A conversion rule between commonly used instruments would aid such comparisons. The present study aimed to compare the revised Delirium Rating Scale (DRS–R98) and Memorial Delirium Assessment Scale (MDAS) in a palliative care population and derive conversion rules between the two scales. Method: Both instruments were employed to assess 77 consecutive patients with DSM–IV delirium, and the measures were repeated at three-day intervals. Conversion rules were derived from the data at initial assessment and tested on subsequent data. Results: There was substantial overall agreement between the two scales [concordance correlation coefficient (CCC) = 0.70 (CI95 = 0.60–0.78)] and between most common items (weighted κ ranging from 0.63 to 0.86). Although the two scales overlap considerably, there were some subtle differences with only modest agreement between the attention (weighted κ = 0.42) and thought process (weighted κ = 0.61) items. The conversion rule from total MDAS score to DRS–R98 severity scores demonstrated an almost perfect level of agreement (r = 0.86, CCC = 0.86; CI95 = 0.79–0.91), similar to the conversion rule from DRS–R98 to MDAS. Significance of results: Overall, the derived conversion rules demonstrated promising accuracy in this palliative care population, but further testing in other populations is certainly needed

Increasing delirium skills at the front door : results from a repeated survey on delirium knowledge and attitudes

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