Elective arthroplasty patients are predominantly older adults, which increases the likelihood of postoperative complications such as delirium. Delirium is an acute and transient neuropsychiatric syndrome involving altered consciousness and cognition.1 The estimated incidence of postoperative delirium (POD) in older adults undergoing elective arthroplasty surgery is 17%,2 and the enhanced susceptibility of older adults to POD development can result in adverse outcomes.3,4
Treatment for delirium is largely confined to a hospital setting, and insight into the follow-up treatments for POD patients post-discharge is lacking. The National Institute for Health and Care Excellence (NICE) and the Scottish Intercollegiate Guidelines Network (SIGN) guidelines advise that each patient’s delirium experience should be documented on the discharge letter to their General Practitioner (GP), to aid in the transfer of care through clinical follow-up.5,6 However, the literature suggests an absence of established clinical follow-up services in delirium care.7 Hence, this study aimed to determine current screening, documentation and follow-up practices for patients undergoing elective arthroplasty in the United Kingdom (UK) and Republic of Ireland (ROI) and subsequently develop POD.
This study was approved by the Faculty of Medicine, Health and Life Sciences Research Ethics Committee at Queen’s University Belfast (MHLS 22_32).
The following sources were used to determine the number of possible respondents, the hospitals and their throughput: (i) National Joint Registry (NJR) hospital profile; (ii) Scottish Arthroplasty Project (SAP); (iii) Irish National Orthopaedic Register (INOR).
A survey for clinicians was constructed and hosted via Google Forms. The research aim was stated at the beginning of the survey, along with a statement of participant consent and an option to withdraw. The survey comprised nine questions, combining multiple-choice and free-text responses. Respondents were asked how delirium is screened and followed-up after elective arthroplasty surgery in their institution (Table 1). Additionally, the respondents were asked to indicate if they worked in the UK or ROI.
Relevant professional bodies agreed to assist survey dissemination to their members. An email containing a survey link was sent to clinicians in the UK and ROI by the Arthroplasty Care Practitioner’s Association (ACPA_ and the British Geriatrics Society (BGS), with an online survey period between 15th February to 3rd March 2022. Twitter was used to highlight and further disseminate the survey on 16th February 2022 inviting all UK and ROI-based clinicians who carry out delirium assessments after elective arthroplasty surgery to take part. In addition, consultant geriatricians and orthopaedic surgeons shared the survey, via email, with relevant contacts.
All responses were fully anonymous, ensuring respondents and their workplaces could not be identified. Data were handled fully in accordance with General Data Protection Regulation.
Number of respondents and context
Of the 404 hospitals in England, Wales and Northern Ireland performing elective hip and knee arthroplasties, 43 hospitals perform >1000 arthroplasties annually, 106 hospitals perform 600-1000, and 99 hospitals perform 400-600.8 In Scotland, 17 hospitals perform elective arthroplasty surgery, and 12 in ROI. Between 15th February - 3rd March 2022, the survey had 43 respondents (Supplementary Material).
18/43 respondents (42%) stated that delirium is routinely screened for in their hospital, with the remaining 25 respondents either stating no (n=16) or don’t know (n=9). Additionally, 11 respondents (44%) confirmed that doctors perform delirium screening in their institution, the most frequently selected profession in both UK and ROI respondents. The second most common response was nurse (n=6), followed by the don’t know option (n=5), occupational therapist (n=1), physiotherapist (n=1) and other (n=1). Free text responses detailed which screening tools are used, with 17 respondents stating that the 4AT tool is used to screen for delirium.
Communication and follow up of postoperative delirium
Subsequently, 26/43 respondents (62%) indicated that delirium development post-elective arthroplasty surgery is communicated via discharge letter to the patient’s GP. Only six respondents (14%) confirmed that follow-up for delirium post-arthroplasty surgery is planned and offered in their hospital. Regarding who performs delirium follow-up, 19/43 respondents provided a response, of which the majority (n=12), stated that they didn’t know. Only four respondents selected a specific team which performs delirium follow-up, three of which selected current care team and one selected referral to memory clinic. Free text details of clinical follow-up services were given in 11 responses (26%) (supplementary material).
Respondents indicating they worked in UK were asked whether they work within the NHS or private hospitals. All 29 UK respondents worked NHS hospitals. The remaining 14 respondents worked in the ROI.
This survey suggests a post-elective arthroplasty delirium screening rate of 42% in the UK and ROI, despite NICE and SIGN guidelines recommending that all high-risk older adults undergoing elective arthroplasty should be screened for delirium.5,6 The reported delirium documentation rate of 62% is substantially higher than previous studies demonstrating delirium documentation frequencies ranging from 3-39%.9,10 However, no insight was gained into the quality of documentation. Research suggests a high incidence of poor documentation quality is associated with poor treatment plans.11 Delirium screening and communication to primary care on discharge are recommended5,6 and these foundations need to be robustly established before meaningful follow-up can be rolled out.
Of the 43 respondents to this survey of clinicians across the UK and ROI, only 14% reported clinical follow-up of people with postoperative delirium following elective arthroplasty. These findings are consistent with previous research that suggests delirium clinical follow-up services are “poor” with “glaring gaps”.7 Clinical follow-up can facilitate the monitoring of patient recovery and improve health outcomes.12 However, only 14% (6/43) of respondents stated clinical follow-up for delirium was planned and offered, with 26% describing potentially relevant clinical follow-up services.
The variety of follow-up practices reported suggests a lack of established, standardised services. Standardisation is crucial to ensure outpatient care quality and improve patient outcomes.13,14 More accurate dementia and cognitive decline risk prediction is needed to guide patient selection for follow-up. Research into appropriate and effective follow-up methods is also required.
This survey is the first to investigate the clinical follow-up available for elective arthroplasty patients that develop POD. While 43 (29 UK-based) respondents is a relatively small sample, it could reflect a significant proportion of the very high volume arthroplasty units in the UK. The anonymity afforded to respondents may have encouraged frank answers. However, it does mean the respondents’ specialties, hospitals and jurisdictions cannot be confirmed. Certain centres may be over-represented, for example 12 units are performing elective arthroplasties in ROI, and this survey had 14 ROI-based respondents. The authors are grateful to ACPA and the BGS for their support in disseminating this survey to their members. Targeting the breadth of practitioners working with elective arthroplasty patients is challenging. If this survey were to be repeated using NHS structures, it would likely continue to encounter difficulties reflecting the overlapping disciplines and specialities providing care in elective orthopaedic units.
The relatively low incidence of delirium screening and communication of delirium diagnosis suggests these cornerstones need to be reinforced. That only 14% of respondents to this survey reported clinical follow-up services for POD reflects the lack of recommendations regarding follow-up of postoperative delirium, with the bulk of guidance available focussed on prevention and in-patient treatment. This study highlights the need for more robust screening and documentation of post-arthroplasty delirium. In addition, more accurate dementia and cognitive decline risk prediction and evidence to support appropriate intervention measures are required to guide post-arthroplasty delirium follow-up.
All research took place online within the Centre for Public Health of Queen’s University Belfast. Additionally, I am grateful to the Arthroplasty Care Practitioner’s Association (ACPA) and the British Geriatrics Society (BGS) for their assistance in distributing the survey to the participants of this study.