Perceptions of the Recognition and Under-Documentation of Postoperative Delirium By Stakeholder Providers: A Situational Analysis

Purpose:

The pupose of this study is to explore the recognition, and under-documentation of postoperative delirium from the perspective of the stakeholder providers involved in perioperative care.

The medical record provides a trail or verification of all treatments procedures and responses of the patient, as well as the accountability of the healthcare provider. It also presents the occurrence and care history in an accurate time frame from admission to discharge. Even so, the incidence of postoperative delirium is frequently under-documented in the medical records and perspectives, and decision making of providers do not appear in the record.

Postoperative delirium is a predictor of functional decline and institutionalization among the elderly surgical patients. Increased post-operative complications, health service utilization, and mortality are also attendant to postoperative delirium(Abelha, 2013; Quinlan, 2011; Rudolph, 2011). Although postoperative delirium is a common complication of major surgical cases, as many as 80% of cases may go undiagnosed or untreated. Studies that explored the recognition rate of postoperative delirium among nurses and physicians suggest it is between 20%- 50%., and both retrospective and prospective studies show that administrative databases underestimate its occurrence (Ely, 2004; Voyer, 2008).

Problem

During the last 15 years, several studies have reported discrepancies between actual and documented cases of postoperative delirium. One study reported that even with a conclusive diagnosis of delirium using diagnostic instruments at the bedside, for three consecutive days, no formal diagnosis or clinical indications were documented in the medical records of the patients, for those days(Millisen, 2002). More recently, 25 cases of delirium identified at the bedside by a specialist team, of those, near one-third did not have their diagnosis reflected in the medical records. Only nine of the 25 reported cases had a delirium diagnosis explicitly documented by the physician (Hope, 2014)).

Simultaneously, during the same 15 years, validated instruments to facilitate the early diagnosis of postoperative delirium, such as the Confusion Assessment Method (CAM, &CAM-ICU)  and the Intensive Care Delirium Screening Checklist (ICDSC) became easily accessible for use at the bedside. Today there are 11 screening tools available (Wong, 2010).  However, studies have reported that they have not been adopted in routine clinical practice  (Andrews, 2015; Bergeron, 2001; Marcantonio, 2013).  The perspective of providers concerning recognition of POD and use of its screening tools remains less described.

The Gap

This qualitative study explored the provider stakeholder’s perspective concerning the prevention, recognition, documentation, and treatment of postoperative delirium. The long-term goal of this inquiry is to understand the facilitators and barriers to the documentation of postoperative delirium to identify where Veterans in the perioperative period may be missed. Under- documentation has significant implications for early recognition, intervention and treatment, and consequently important clinical implications for patient care and desired outcomes. Less considered, providers are often less cognizant of the role of postoperative delirium in association with post-discharge worsening of quality of life, change in mental status, sleep disturbance, cognitive decline, institutionalization, and increased mortality. While postoperative delirium remains under-represented in the electronic medical record, it will not receive the attention required to foster interest and research into its prevention and early intervention. The perspectives of stakeholder providers in the US Department of Veteran Affairs (VA) health system could deliver essential initial exploratory information for proposing interventions to improve documentation.

Methods:

The qualitative approach of situational analysis as a form of grounded theory was used to frame this study to permit the voices of providers across the perioperative service spectrum to produce data. The purposive sample consisted of two stakeholders from each of six departments in the community of practice involved in elective surgery:  primary care, specialty clinic, anesthesia, surgery, mental health, and Intensive Care Surgical Unit nurses.  Four pragmatic, open-ended, semi-structured questions, focusing on the “how” and “why” of documentation and perceptions of postoperative delirium were used to interview each participant separately. This format permitted the conversation to go in directions that positioned the experiences of each participant as central to the answers provided.Data collection began after approval was recieved from the IRB and the Veteran Affairs Research and Development Committee. The twelve digitally recorded interviews were stored securely in a password-protected, firewalled server, transcribed by VA-approved personnel and then analyzed by the team.

Data Analysis

The data was analyzed using the process of situational analysis to code transcriptions line-by-line to produce messy maps of perceptions across the community of practice.  This form of grounded theory, like its predecessors, is dependent on established ideas of theoretical sensitivity and sampling, constant comparative methods, coding, memoing and diagramming. Coded concepts were diagramed and developed into maps that are the basis for higher-level analysis. The three types of maps produced are situational maps, social worlds/arenas maps and positional maps. Based on the situation of concern, broad categories were drawn out from the maps and a relational analysis used to ask questions of the categories performed and the answers documented  (Charmaz, 2006; Clarke, 2005). The themes that emerged from the data analysis are fundamental to gaining a better understanding of the factors that influence the under-documentation of postoperative delirium affected by predisposing factors that emerged from the interviews.

Results:

The following themes emerged as the most commonly mapped from described perioperative situations.

“Territory vs. Power.” Although the nurses are in charge of the territory in which the patient resides, they have constrained power over the identification of relevant conditions or treatments for the patients in that space. ICU nurses expressed a feeling of an undervaluing of their assessment skills, as the physicians do not respond to their report of changes in patient’s mental status as an observed situation. Physicians come and go spending brief moments at the bedside while postoperative delirium characteristically fluctuates between lucidity and disorientation.

Lack of standardization of nomenclature.The language used to describe postoperative delirium within situations contributes to the difficulty of identifying the syndrome. If the diagnosis is considered sundowner syndrome, then treatment might be delayed. As an attribution given to older people who become confused as the situational day ends, sundowner has no urgency. For the patient with a previous history of mental health disorders, they may, in fact, be withdrawing from psychotropic drugs not resumed after surgery, a situation named and noticed too late. These variations lay bare the need for more meticulous assessment and risk stratification; that is basic to instruments such as the Comprehensive Geriatric Assessment tool.

Lack of a definitive biomedical identifier. The physicians note that there is a lack of a definitive measure or lab test for identifying postoperative delirium when suspected or identified in a situation, to recognize the phenomenon within its place and time. There is no staging as in cancer or a value such as an A1C that reveals diabetes. Some nurses report that they are very much aware of the subtle change that accompanies the decline into postoperative delirium. However, the nurses admit they do not use the instruments for early recognition of delirium, even though they are readily available.

Truthfulness:  In reflecting on situations of assessment, providers often described patients with substance use as seldom truthful about their use. Nurses and physicians described themselves as only aware once the substance withdrawal is in full bloom. Alcohol withdrawal becomes a default diagnosis. Treatment begins only after all other possibilities are ruled out. However, the dilemma is that withdrawal is best treated early, especially alcohol withdrawal since it can be fatal. Consequently, the absence of important components of social history in the medical history may lead to a delay in appropriate care.

Lack of knowledge:  Across perioperative situations, when providers did not screen, predict or diagnose postoperative delirium, the condition went under-documented. Their responses suggest a lack of understanding of the consequences of the syndrome both by nurses and physicians who do not see beyond their territory, resulting in negligible communication about postoperative delirium across the services.

Conclusion:

As a situation arising in the process of recovery from major surgery, the occurrence of postoperative delirium is complicated by the ability of providers across the perioperative spectrum to isolate it. In mapping its appearance, the event requires prevention or separation of the occurrence apart from the routine events of recovery for identification or documentation. The patient, however,  may not escape the deleterious consequences of postoperative delirium in the situation of their recovery and potentially long after. Findings suggest a variety of ways to encourage stakeholders to screen for modifiable risk factors and use the tools available to identify postoperative delirium. Without adopting evidence-based procedures or a set of guidelines, critical care clinicians are left without a standardized means of identifying and documenting delirium, while their colleagues across the perioperative spectrum are left outside the domain with a need for education for prevention. Post-operative delirium becomes a syndrome without a home in need of intervention but without interdisciplinary ownership within the community of practice.