Diverging Awareness of Postoperative Delirium and Cognitive Dysfunction in German Health Care Providers

Abstract

Purpose

Postoperative cognitive dysfunction (POCD) appears in up to 30% of patients suffering from postoperative delirium (POD). Both are associated with higher mortality and postoperative complications, prolonged hospital stays, and increased costs. Multi-modal models with pre-admission risk reduction counselling, perioperative monitoring, and training of multidisciplinary patient care providers have been shown to decrease the prevalence of both. The aim of our study is to understand how far those measures are known and implemented in routine care and to detect potential gaps in the current practice regarding risk communication and information flow between involved caregivers for patients at risk for POD/POCD.

Patients and Methods

As part of a multicenter study, seven semi-structured focus group (FG) discussions with nurses and physicians from tertiary care hospitals (surgery, anesthesiology, and orthopedics, n=31) and general practitioners (GPs) in private practice (n=7) were performed. Transcribed discussions were analyzed using qualitative content analysis.

Results

POD is present above all in the daily work of nurses, whereas physicians do not perceive it as a relevant problem. Physicians report that no regular risk assessment or risk communication was performed prior to elective surgery. Information about POD often gets lost during hand-offs and is not regularly reported in discharge letters. Thus, persisting cognitive dysfunction is often missed. The importance of standardized documentation and continuous education concerning risks, screening, and treatment was emphasized. The often-suggested pre-OP medication adjustment was seen as less important; in contrast, avoiding withdrawal was regarded as far more important.

Conclusion

Altogether, it seems that standards and available best practice concepts are rarely implemented. In contrast to physicians, nurses are highly aware of delirium and ask for standardized procedures and more responsibility. Therefore, raising awareness regarding risks, screening tools, and effective preventive measures for POD/POCD seems an urgent goal. Nurses should have a central role in coordination and care of POD to prevent the risk for POCD.

Keywords:

• cross-sectoral care
• delirium prevention
• postoperative cognitive dysfunction
• POCD
• dementia
• clinical pathways
• risk screening

Acknowledgments

We thank all participants of the focus groups as well as the PAWEL Consortium for the organizational support. This study is funded by the Innovationfonds 01VSF16016 (PAWEL).

Abbreviations

POD, post-operative delirium; POCD, post-operative cognitive dysfunction; FG, focus group; GP, general practitioner; CIS, clinical information system.

Ethics Approval and Clinical Trial Register Details

The PAWEL study was approved by the Ethics Commission of the Faculty of Medicine of the Eberhard-Karls University and University Hospital Tübingen with number 517/2017BO1 on the 12 October 2017 (amendment for focus groups on 17 May 2018) and by the Ethics Commission of the University of Potsdam with number 38/2017 on the 11 December 2017. PAWEL was registered on the German Clinical Trials Register (number DRKS00013311; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00013311) on 10 November 2017.

Author Contributions

HS, RW, and SJ designed this study. RW, LB, HS, and RS conducted focus groups and performed and discussed structured content analysis. GE, CT, and SJ supported participant acquisition for the focus groups. HS drafted the manuscript supported by RW. All authors contributed to and approved the final draft, contributed to data analysis and drafting or revising the article, gave final approval of the version to be published, and agreed to be accountable for all aspects of the work.

Disclosure

Mrs L Bertram reports grants from Innovationfonds outside the submitted work. Prof. Dr. G Eschweiler reports grants from Innovationsfonds PAWEL, during the conduct of the study. Dr C Thomas reports grants from Innovation fund G-BA, during the conduct of the study. Prof. Dr. M Rapp reports grants from BMBF during the conduct of the study and personal fees from Willmar Schwabe GmbH outside the submitted work. The authors report no other conflicts of interest in this work.