doi:10.1111/1744-1609.

12004 Int J Evid Based Healthc 2013; 11: 39–45

EVIDENCE UTILISATION

Implementing the best available evidence in early delirium

identification in elderly hip surgery patients
Kathleen Ann Russell-Babin RN MSN1 and Helen Miley RN PhD2
1
Meridian Health, Institute for Evidence-Based Care, and 2Meridian Health, Ann May Center for Nursing and Allied Health, Neptune,
NJ, USA

Abstract
Aims Delirium is a frequent complication in the surgical experience of elderly hip surgery patients. Its impact can
be severe and may even include death. Implementation of a delirium predictor tool might focus attention on early
recognition of delirium, thereby potentially decreasing its impact. A related aim is to evaluate best practices in
implementation strategies in this project.
Methods After an exhaustive search of the literature, no consensus was found regarding delirium predictors for the
elderly hip surgery patient. A local research study was implemented to determine factors that may predict delirium
in this population. With evidence secured, a multidisciplinary implementation project augmented by ongoing audit
was instituted. A variety of social diffusion and education tools were used. Implementation was guided by the use
of the Promoting Action on Research Implementation in Health Services framework assessment tool and the Alberta
Context Tool, as well as traditional performance improvement tools, such as fishbone charting. Audit identified the
rate of use of the predictor tool and pre- and post-rates of delirium. This project was part of the Joanna Briggs
Institute Signature Project, an implementation project consisting of six teams, each representing a different organi-
sation. This overall project was supported by experts in the field of translation and implementation science
internationally.
Results Initial compliance to the use of the predictor tool was assessed at 54% within 3 months of implementation
and increased to 56% in the ensuing months. Before the study use of the predictor tool, the delirium rate was 10.4%
(12 of 115 patients). An interim analysis 4 months after implementation identified a 20% delirium rate (18 of 70
patients) and an updated analysis 8 months into the project showed a 16.3% delirium rate. Delirium predictor tool
use was associated with a lower delirium rate (9/76, 11.84%) than no delirium predictor tool (13/60, 21.67%), but
the difference was not statistically significant with a sample size of 133 (P = 0.122).
Conclusions The delirium predictor tool shows promise as a prompt for best practices in prevention of delirium.
This study showed a change in delirium rates as a result of its use. Although the results were not statistically
significant, they may be clinically meaningful. Comprehensive assessment and implementation planning by a
multidisciplinary team contributed to only 56% compliance in use. Despite this low rate, delirium identification rates
were higher.
Key words: evidence-based practice, gerontology, implementation, orthopaedic.

Introduction cations,2,3 longer length of stay,3,4 discharge to institutional

Elderly hip surgery patients often experience increased
delirium rates. Such patients may have delirium rates as high
as 61%.1 Delirium is associated with higher rates of compli-
Correspondence: Ms Kathleen Ann Russell-Babin, Meridian Health,
Institute for Evidence-Based Care, Neptune, NJ 07753, USA. Email:
krussellbabin@meridianhealth.com
care2–4 and even death.4 Delirium assessment, prediction
and care are the subject of much attention in the literature
over several decades. It remains an area ripe for improve-
ment. This article will trace the journey of evidence assess-
ment and implementation on delirium prediction in hip
surgery patients.
The hospital involved in this project is a Nursing Improv-
ing Care for Healthsystem Elders facility and its nurses have

© 2013 The Authors

International Journal of Evidence-Based Healthcare © 2013 The Joanna Briggs Institute
40 KA Russell-Babin and H Miley

been identified for their excellence by the American Nurses Table 1 Sources of evidence for predictors of delirium
Credentialing Center Magnet Recognition program Predictor Source
(Magnet). Magnet designation recognises organisations
throughout the world for demonstrating superior patient Age Marcantonio et al.,3 Galanakis
care and practice environments that support nurse develop- et al.,9 Freter et al.,10 Kalisvaart
et al.,11 Vaurio et al.,12 Priner
ment. The hospital is a member of a prominent health
et al.,13 Ansaloni et al.14
system that maintains high emphasis on research, educa- Emergent status Bowman,15 Duppils and
tion, shared governance and clinical excellence. It maintains Wiklblad,16 Kalisvaart et al.,11
a staff of five nurse scientists and a separate interdisciplinary Dasgupta and Dumbrell,17
institute for evidence-based care. Galanakis et al.9
This project was initiated as part of knowledge translation CV disease Duppils and Wiklblad16
workgroup sponsored through the Joanna Briggs Institute. Delay in surgery Duppils and Wiklblad16
International leaders in evidence translation and implemen- Hearing impairment Duppils and Wiklblad16
tation guided six healthcare organisations through a knowl- Vision impairment Freter et al.10
edge translation project entitled the Signature Project. Hypotension Edlund et al.2
Dependent living Duppils and Wiklblad16
Members of the team from this single hospital in central
Male gender Fisher and Flowerdew,18 Edlund
New Jersey focused on the subject of delirium in elderly hip et al.2
surgery patients. Reduced clock drawing Fisher and Flowerdew18
This article will Substance issues, alcohol Freter et al.10
• Outline the research secured to initiate an evidence-based or benzodiazepines
delirium predictor project Cognitive impairment Marcantonio et al.,3 Freter et al.,10
• Describe the translation team’s assessment of readiness for Duppils and Wiklblad,16
evidence-based practice change Kalisvaart et al.11
• Delineate the implementation team activities Reduce activities of Marcantonio et al.,3 Freter et al.10
• Share the data collection process before and after predic- daily living
Depression Galanakis et al.,9 Juliebø et al.,19
tor tool implementation
Leung et al.20
• Discuss the results, conclusions and implications Lower educational level Galanakis et al.9
In the literature, the experience of delirium is seen since Lower sodium Marcantonio et al.,3 Galanakis
the days of Hippocrates,5 yet it remains elusive even today. et al.,9 Zakriya et al.21
The roots of delirium have been traced to the Latin word APACHE II level Kalisvaart et al.11
meaning ‘off the track’.6 Delirium is an abrupt, transient and Attention deficit Lowery et al.22
fluctuating disturbance in consciousness, cognitive function Lower potassium Marcantonio et al.3
or perception. The symptoms can vary from lethargy (silent Lower glucose level Marcantonio et al.3
or hypoactive) to hyperagitation.7 The surgical geriatric Faecal incontinence Shuurmans et al.23
patient is especially prone to the development of delirium, Inability to bathe self Shuurmans et al.23
Comorbid psychiatric Shuurmans et al.23
with the highest reports in orthopaedic surgery and vascular
Multiple comorbilities Shuurmans et al.23
surgery.8 It is noted early in the postoperative period, typi- Preoperative pain Vaurio et al.12
cally on the first or second day. Increased pain Vaurio et al.12
A review of the literature was performed by the authors to Parenteral pain medication Vaurio et al.12
determine the state of the science in delirium prediction, Normal WBC Zakriya et al.21
with a special focus on elderly hip surgery (both elective and ASA class Zakriya et al.21
emergency patients). Over 40 predictors of postoperative Fracture indoors Juliebø et al.19
delirium (POD) were identified (see Table 1 for list and BMI < 20 Juliebø et al.19
sources). Little consensus was found, although several studies Cumulative illness rating Ansaloni et al.14
posed emergency surgery as a predictor variable. The rigor of High glucose Ansaloni et al.14
HADS (depression) Ansaloni et al.14
the studies available varied tremendously, with most catego-
Mental status Ansaloni et al.14
rised as either prospective cohort or observational studies. Restraints Inouye24
Studies often used convenience samples. The patients that More than three Inouye24
were included and excluded had no consistency. At times, medications
studies excluded variables that were predictive in other inves- Foley catheter Inouye24
tigations. The available evidence was considered insufficient Iatrogenic event Inouye24
to direct predictors in this population. IQCODE Priner et al.13
A local retrospective chart review of randomly selected Blood loss Priner et al.13
elderly patients from 2010 who underwent hip surgery was Psychotropic drugs Priner et al.13
conducted. This research identified three factors that corre- Mini-Mental Status Evaluation Priner et al.13
lated with POD: benzodiazepine use on day 1 postop, low BMI, body mass index; CV, cardiovascular; WBC, white blood cell.
haematocrit on day 1 postop and history of depression.
Surprisingly, emergency surgery did not appear. Because of

© 2013 The Authors

International Journal of Evidence-Based Healthcare © 2013 The Joanna Briggs Institute

its prominence as a predictor in five studies, the research
team retained it as a predictor for continued testing. A final
predictor tool of these four variables was adopted for use.
This article will detail the course of this evidence production.
Translating evidence into practice is social, political and
educational experience. Accordingly, a variety of social dif-
fusion and education tools were used to support the imple-
mentation of this tool into practice. The organisation’s
experience in evidence implementation will be shared.
Aims/objectives of the project
The overriding goal of this knowledge translation project
was to reduce the incidence and impact of delirium on elders
experiencing hip surgery. Improving identification of
delirium was considered paramount to ensuing patient
safety. The premise of the project is that implementation of
an evidence-based delirium predictor tool (DPT) might focus
attention on early recognition of delirium, thereby poten-
tially decreasing its impact. When the DPT was assessed as
positive, it was expected that the nurse would adopt early
intervention strategies to prevent or lessen delirium. Among
these strategies were diligent use of the confusion assess-
ment method (CAM),25 collaboration with the attending
physician and interdisciplinary team, and implementation of
a delirium prevention plan of care.
Methods
Setting and population
Ocean County is second only to most counties in Florida for
its dominant elderly population. Ocean Medical Centre is a
key location for care of this population and a local leader in
orthopaedic care. Ocean Medical Centre is a 241-bed acute
care facility containing specialised units for acute elderly care
and orthopaedics.
Overview of key stages in the project
Stage 1: evidence review
As was previously noted, a thorough review of the literature
was conducted in search of a composite of predictors of
POD. The initial focus of the query was based upon elderly
hip surgery patients. This produced a limited amount of
articles, so the broader categories of orthopaedic surgery
and then general surgery with at least 40% of the patients in
orthopaedic were reviewed. The goal of the literature review
was to locate a predictor tool already in use and to replicate
its use. What resulted was a larger, diverse set of potential
predictors studied across various institutions globally.
Multiple literature sources (as previously noted in Table 1)
documented a variety of potential predictors of delirium.
Works of Inouye and Charpentier25 and Marcantonio et al.3
in this area are prominent, although work of Inouye and
Charpentier was with a medical population and work of
Marcantonio et al. was with a surgical population. No con-
sensus on predictors was found. The opportunity to perform
local research became evident.
International Journal of Evidence-Based Healthcare © 2013 The Joanna Briggs Institute
Delirium in elderly hip surgery patients 41
Stage 2: local evidence production
This section further summarises the production of local evi-
dence for a predictor tool in elderly hip surgery patients. All
data collection was approved through the local institutional
review board. Data collection was accomplished by the
authors. A standard data collection was created and
approved for use by institutional review process. Prior to the
full data collection, the nurse researchers reviewed a sample
of charts to attain consistency in chart review. There were no
discrepancies, so that the data collection method was con-
sistent and accurate through the process. Every other chart
was accessed pre- and post-implementation of the predictor
tool. In the pre-implementation period, a list of patients who
had undergone hip surgery (identified by corresponding
ICD9 codes for the hip procedure and delirium) in 2010 at
Ocean Medical Center was obtained from the data ware-
house. If a patient had multiple hip surgery dates, only the
first date was used. A chart review was done (every other
chart on the list due to available resource reasons) for evi-
dence of any predictors that were noted in the literature. The
predictors were divided into three categories: preoperative,
intraoperative and postoperative variables (examined on
postop day 1, 2 and 3). Based on the 40 predictors found in
the literature, a total of 59 data points were collected during
the patient’s hospital stay.
The inclusion criteria were adults over the age of 65 who
had hip surgery and completed their postoperative course
in the general ward. Since admission to a critical care area
carries a higher risk of delirium related to additional poten-
tial causative factors, those patients were excluded. Patients
with dementia were also excluded as clinicians in this
system often continue to confuse delirium and dementia.
The focus was to limit as many confounding variables as
possible. A total of 178 charts were examined for manual
data abstraction. A total of 63 charts were not analysed due
to the exclusion criteria above. A final total of 115 charts
were used for analysis. Delirium was considered to be
present when two separate entries of confusion were
evident in the record. At the time of the study, use of CAM
was in its infancy so the gold standard of identification
could not be relied upon. Furthermore, the desire was to
ensure that any incidence was found, ICD-9 coded or not.
The same nurses reviewed the charts preoperatively and
postoperatively.
Of the preoperative factors identified (such as significant
comorbidities, place of residence, vital signs and activities
of daily living), only a history of depression yielded a sig-
nificant association with POD. A total of 12 patients devel-
oped confusion indicating delirium. Twenty-four patients
had a history of depression. Of these, six developed deli-
rium indicating a 25% incidence. This compared with six
patients with delirium out of 91 who had no history of
depression or a 6.6% incidence. This difference was signifi-
cant with the Fisher’s exact test (P-value = 0.018) and logis-
tic regression (P-value = 0.014), showing a 4.72 increase in
odds of delirium if the patients had a history of depression.
No intraoperative factors yielded any significant relationship
to POD.
© 2013 The Authors
42 KA Russell-Babin and H Miley
Postoperative variables proving useful were benzodi-
azepine use on day 1 postoperatively and low haematocrit
on day 1 postoperatively. A multivariate analysis using hae-
matocrit as a dichotomous variable was performed. It was
found that with each unit decrease in haematocrit, the odds
of developing delirium increased 23%. This result was sta-
tistically significant. Day 1 and day 2 use of benzodiazepines
were highly correlated at the univariate level (P = 0.009), but
only day 1 was significant on multivariate analysis. A total of
15 patients received routine oral benzodiazepines the first
day, reflecting a 33.3% incidence of delirium compared with
only 7.1% incidence in patients who did not receive a ben-
zodiazepine (multivariate 6.40 (1.32, 30.93), P = 0.0210).
The final predictor tool included the following variables:
benzodiazepine use on day 1 postop, low haematocrit on
day 1 postop and history of depression. Furthermore, the
variable of emergency surgery was added for further testing.
During the course of this analysis, a pre-evaluation of
delirium rate was assessed. Delirium rate was found to be
10.4%. This low rate seemed logical given the trend of lower
emergency cases and strong practice patterns surrounding
the care of these patients. These practices included such
items as prompt removal of urinary catheters, early ambu-
lation and adequate pain management.
Stage 3: translation team assessment
The authors enlisted the assistance of a staff nurse in active
practice to assess the potential for a successful change in
practice to prevent delirium. This small core team assessed
the barriers to implementation of the newly created pre-
dictor tool using a cause and effect diagram. Three factors
were determined and included expected resistance to
change, potential lack of interest and lack of education.
Lack of education was deemed the most significant of
these. Strengths assessed included supportive leadership,
staff who are highly motivated to improve care for the
elderly and available resources to support the project. An
action plan was derived to provide small group education
utilising case studies to personalise the message of care of
the patient threatened by delirium. This group also used
the Promoting Action on Research Implementation in
Health Services (PARiHS) self-assessment tool to further
determine readiness for evidence implementation.26 Evi-
dence strength was moderately rated, while organisational
strength was highly rated.
Stage 4: use of a project team
Prior to this initiative, few efforts to address delirium existed
and no organised group was responsible for improvement in
care related to delirium. A project team was set up to func-
tion as a steering committee. Various methods to gain par-
ticipation in evidence-based change have been studied and
include education, opinion leader work, computer hard-
wiring, quality improvement data feedback, sophisticated
marketing and incentives. An underlying theory for much of
this work is Rogers’ Diffusion of Innovation.27 Rogers empha-
sises the importance of social interactions within change.
Key stakeholders and opinion leaders must be identified and
© 2013 The Authors
International Journal of Evidence-Based Healthcare © 2013 The Joanna Briggs Institute
involved in the process. Opinion leaders may be effective in
supporting evidence implementation.28 The steering com-
mittee was set up as an interdisciplinary team with high
expertise and interest in the topic and key placement in
various points in the care of the hip surgery patient. The
team involved a geriatrician, a geriatric clinical nurse special-
ist, a geriatric nurse practitioner, a nurse coordinator for
orthopaedics, a charge nurse for orthopaedics, a staff nurse
from post-anaesthesia care, a nurse leader for perioperative
care, a physical therapist serving the orthopaedic popula-
tion, an evidence review expert and a statistician. This team
assumed responsibility for instituting the Alberta Context
Tool.29 The Alberta Context Tool provides insight into the
organisational environment for evidence-based change.
Forty-five team members completed the tool. Results con-
firmed earlier assessments by the core team. Leadership was
highly rated. The organisation seeks best practice, sponsors
staff development, is highly patient centred and has strong
teamwork. Social capital was among the highest areas rated.
Team feedback was moderately high in rating. Furthermore,
the team assumed responsibility for supporting all aspects of
their implementation plan.
Stage 5: description of best practice
In the absence of any literature to guide the process of
predictor tool use, the local steering committee identified
the steps in the process of introducing and using the tool.
Refinements to the appearance of the hard copy predictor
tool were made based upon team feedback (see Fig. 1).
The team supported a prompt for further action in delirium
prevention as part of the tool. This included the reminder
to perform a CAM, a prompt to collaborate with the phy-
sician in charge of the case and encouragement to enact
the standard care plan for delirium prevention available
within the clinical information system. The team created a
small group education package using a standard Power-
Point presentation by the nurse coordinator for orthopaedic
services. A project initiation date was chosen that was
assessed to be free of major concurrent pressures. Audit
and feedback were planned to further support the imple-
mentation of evidence.30
Description of the implementation methods
The steering committee approved a process of predictor tool
use involving both the post-anaesthesia unit and the ortho-
paedic unit. The process involved the following:
• Peri-anaesthesia (post-anaesthesia care unit (PACU)) nurse
case identification
• Volunteer posting of manual form to charts
• Communication handoff of case identification between
PACU and orthopaedic unit
• Orthopaedic unit 7 am dual shift rounding to complete
the predictor tool
• Communication of results to physician
• Prompting for documentation of delirium status in the
existing CAM chapter of the clinical information system on
the DPT documentation form

Figure 1 Delirium predictor tool.
Post-data collection and analysis
Post-implementation, the data elements collected were
pared down to 13. These included the following:
Age; sex
Diagnosis
Emergency surgery status
Haematocrit value
History of depression
Use of benzodiazepines during stay
CAM completed
CAM documented delirium presence
Narrative chart documentation of delirium
Plan of care instituted for delirium in high-risk patients
Length of stay
Discharge disposition
Data were collected after the June 2011 implementation
phase-in through January 2012, in a similar fashion as the
pre-implementation data collection. The analysis primarily
International Journal of Evidence-Based Healthcare © 2013 The Joanna Briggs Institute
Delirium in elderly hip surgery patients 43
focused on what the incidence of delirium was and if the
predictor variables remained significant.
Results
Initial compliance to use of the predictor tool was assessed at
54% within 3 months of implementation and increased to
56% in the ensuing 3 months with revisions to weekend
procedures for tool placement in the chart. Before the study
use of the predictor tool, the delirium rate was 10.4% (12 of
115 patients).
An interim analysis 4 months after implementation iden-
tified a 20% delirium rate (18 of 70 patients) and an updated
analysis 9 months farther into the project in February 2012
showed a 15.8% (25 of 158 patients). Those who used DPT
had 0.475 times odds to develop delirium compared with
those who did not use DPT; in other words, those who used
© 2013 The Authors
44 KA Russell-Babin and H Miley
DPT have half the odds to develop delirium than those who
did not use it.
Ongoing assessment of the fit of the local delirium pre-
dictor variables was performed. In the post-implementation
analysis, the only significant variables for delirium prediction
in the local population were age and emergency surgery.
The original variables did not hold true in this second cohort.
The post-implementation group was older than the pre-
implementation group. Those experiencing delirium in the
pre-analysis group were 77.3 years of age, while those
experiencing delirium in the post-analysis group were an
average of 83.22 years of age. Emergency status was 40% in
the pre-implementation group and 37.3% in the post-
implementation group.
Despite these findings, the DPT did demonstrate some
overall predictive power. An analysis of 80 patients who had
a DPT used showed a sensitivity of 88.8% (proportion of
delirious patients correctly identified) and a specificity of
49.3% (proportion of non-delirious patients correctly iden-
tified). The positive value predictive value (or the percent-
age of patients at high risk of delirium as predicted by the
DPT who really developed delirium) result was 18.2%. The
negative value predictive value (or the percentage of
patients not at risk for delirium as predicted by the DPT
who did not develop delirium) was 97.2%. The Fisher’s
exact test for the difference in delirium rates between those
identified by DPT and those not was significant at a P-value
of 0.037. In those at high risk, as determined by the DPT,
8/44 of 18.2% developed delirium, where those who were
not at high risk as depicted by DPT experienced a rate of
only 2.78%.
Documentation of CAM was confounded throughout the
study as the nurses were allowed to document condition
unchanged and not systematically evaluate each component
of the CAM assessment. While CAM was ‘documented’ 95%
of the time, if one accepts the status unchanged indicator,
chart narratives more accurately depicted the presence of
delirium both before and after the project.
Delirium predictor tool use was designed to prompt a
delirium care plan. This was part of the educational compo-
nent to the nurses and the tool clearly re-emphasised this.
There were 110 instances of where either the DPT was not
used or the DPT results were negative. This left 47 cases
where DPT data were available (one missing case existed).
Of these 47 cases where DPT was available and positive on
more or more variables, delirium was evident in eight cases
(10.6%). Care plans were initiated in 17 cases or only 36%
of the time. The statistical analysis showed no significant
relationship between the rate of delirium and the plan of
care initiated.
Discussion/conclusion
The use of a predictor tool for delirium has two reasonable
outcomes: (i) delirium is prevented and the rate is lower or
(ii) delirium is increased as the identification is greater. The
latter conclusion is seen in this performance improvement
project. A change in the results was evidenced despite only
© 2013 The Authors
International Journal of Evidence-Based Healthcare © 2013 The Joanna Briggs Institute
56% compliance in the use of the tool. Results were clinically
meaningful although not statistically significant.
The PARiHS model calls for both evidence and context to
be highly effective in order to best move evidence into
practice. A major challenge in this project was the evidence
quality. Initial expectations were that with the large amount
of research performed on this subject, consensus on predic-
tors or risk factors would be easily seen. This was not the
case. The team then generated local research to identify
their own predictors for their population. Three predictors
were found. Sustained success was not within their grasp,
however, as the original predictors did not remain stable in
subsequent follow up. Modest predictive ability exists in the
original tool. All in all, evidence strength followed a jagged
course. This factor was the major contributor to the lack of
success in the use of the predictor tool.
Confusion assessment method documentation and care
plan use remain confounded by a myriad of practical issues.
The clinical value of the current CAM documentation has led
the steering committee to adopt a pilot policy on this unit
that CAM elements must be documented, in full, each shift.
The element ‘no change from prior shift’ will no longer be
possible. Care plans are currently being updated on the
topic to ensure maximum relevance.
Delirium remains a less than optimally managed condi-
tion. Delirium experts see delirium as an indicator of the
overall quality of care rendered in hospitals today.31 The
literature indicates that clinicians do not recognise
delirium.32 Healthcare professionals are challenged to make
incremental improvements in care of patients at risk for
delirium given its profound impacts.
A primary limitation of this work was that both the evi-
dence and the implementation were carried out on one unit
in one hospital, in central New Jersey. Efforts are underway
to assess predictors in other facilities of this healthcare
system.
The role of predictor tools may go beyond their face value
as they may serve as a reminder tool for best practice. That
may be the clearest lesson learned through this work to date.
Care improvement often needs to begin at the front end of
the process, in the awareness and assessment stages. This
study endeavoured to impact this fundamental phase of the
care process. A modest result was seen despite the use of
best practices in evidence introduction.
Acknowledgements
The authors acknowledge the contributions of Ms Amy
Wozniak, MS, biostatistician, Clare Tang, MS, biostatistician
and Ms Sharon Lubeck, RN at the local level and Susan
Salmond, Cheryl Holly, Alison Kitson, Rick Weichula, Tiff
Conroy and Tim Schultz at the Signature Project level.
References
1. Gustafson Y, Berggren D, Brännström B et al. Acute confusional
states in elderly patients treated for femoral neck fracture. J Am
Geriatr Soc 1988; 36: 525–30.

2. Edlund A, Lundström M, Brännström B, Bucht G, Gustafson Y.
Delirium before and after operation for femoral neck fracture.
J Am Geriatr Soc 2001; 49: 1335–40.
3. Marcantonio ER, Goldman L, Mangione CM et al. A clinical
prediction rule for delirium after elective noncardiac surgery.
JAMA 1994; 271: 134–9.
4. Robinson TN, Raeburn CD, Tran ZV, Angles EM, Brenner PA,
Moss M. Postoperative delirium in the elderly: risk factors and
outcomes. Ann Surg 2009; 249: 173–8.
5. Berrios GE. Delirium and confusion in the 19th century: a con-
ceptual history. Br J Psychiatry 1981; 139: 439–49.
6. Massey EW, Coffey CE. Delirium: diagnosis and treatment.
South Med J 1983; 76: 1147–50.
7. Young J, Inouye SK. Delirium in older people. BMJ 2007; 334:
842–6.
8. Siddiqi N, Hot R, Britton AM, Holmes J. Interventions for pre-
venting delirium in hospitalized patients. Cochrane Database
Syst Rev 2007; CD005563. doi: 10.1002/14651858.CD005563.
pub2.
9. Galanakis P, Bickel H, Gradinger R, VonGumppenberg S, Förstl
H. Acute confusional state in the elderly following hip surgery:
incidence, risk factors and complications. Int J Geriatr Psychiatry
2001; 16: 349–55.
10. Freter SH, Dunbar MJ, MacLeod H, Morrison M, MacKnight C,
Rockwood K. Predicting post-operative delirium in elective
orthopaedic patients: the Delirium Elderly at-Risk (DEAR) instru-
ment. Age Ageing 2005; 34: 169–71.
11. Kalisvaart KJ, Vreeswijk R, deJonghe J et al. Risk factors and
prediction of postoperative delirium in elderly hip-surgery
patients. J Am Geriatr Soc 2006; 54: 817–22.
12. Vaurio LE, Sands LP, Wang Y, Mullen EA, Leung JM. Postopera-
tive delirium: the importance of pain and pain management.
Anesth Anal 2006; 102: 1267–73.
13. Priner M, Jourdain M, Bouche G, Merlet-Chicoine I, Chaumier J,
Paccalin M. Usefulness of the short IQCODE for predicting
postoperative delirium in elderly patients undergoing hip
and knee replacement surgery. Gerontology 2008; 54:
116–9.
14. Ansaloni L, Catena F, Chattat R et al. Risk factors and incidence
of postoperative delirium in elderly patients after elective and
emergency surgery. Br J Surg 2010; 97: 273–80.
15. Bowman AM. Sleep satisfaction, perceived pain and acute con-
fusion in elderly clients undergoing orthopaedic procedures.
J Adv Nurs 1997; 26: 550–64.
16. Duppils GS, Wiklblad K. Acute confusional states in patients
undergoing hip surgery. Gerontology 2000; 46: 36–43.
17. Dasgupta M, Dumbrell AC. Preoperative risk assessment for
delirium after noncardiac surgery: a systematic review. J Am
Geriatr Soc 2006; 54: 1578–89.
International Journal of Evidence-Based Healthcare © 2013 The Joanna Briggs Institute
Delirium in elderly hip surgery patients 45
18. Fisher BW, Flowerdew G. A simple model for predicting post-
operative delirium in older patients undergoing elective ortho-
pedic surgery. J Am Geriatr Soc 1995; 43: 175–8.
19. Juliebø V, Bjøro K, Krogseth M, Skovlund E, Ranhoff A, Wyller
TB. Risk factors for preoperative and postoperative delirium in
elderly patients with hip fracture. J Am Geriatr Soc 2009; 57:
1354–61.
20. Leung JM, Sands LP, Mullen EA, Wang Y, Vaurio L. Are preop-
erative depressive symptoms associated with postoperative
delirium in geriatric surgical patients? J Gerontol A Biol Sci Med
Sci 2005; 60: 1563–8.
21. Zakriya KJ, Christmas C, Wenz JF, Franckowiak S, Anderson R,
Sieber FE. Preoperative factors associated with postoperative
change in confusion assessment method score in hip fracture
patients. Anesth Anal 2002; 94: 1628–32.
22. Lowery DP, Wesnes K, Ballard CG. Subtle attentional deficits in
the absence of dementia are associated with an increased risk of
post-operative delirium. Dement Geriatr Cogn Disord 2007; 23:
390–4.
23. Shuurmans M, Duursma S, Shortridge-Baggett LM, Clevers G,
Pel-Little R. Elderly patients with a hip fracture: the risk for
delirium. Appl Nurs Res 2003; 16: 75–84.
24. Inouye SK. A practical program for preventing delirium in
hospitalized elderly patients. Cleve Clin J Med 2004; 71: 890–6.
25. Inouye SK, Charpentier PA. Precipitating factors for delirium in
hospitalized elderly persons; predictive model and interrelation-
ship with baseline vulnerability. JAMA 1996; 275: 852–7.
26. Kitson AL, Rycroft-Malone J, Harvey G, McCormack B, Seers K,
Titchen A. Evaluating the successful implementation of evi-
dence into practice using the PARiHS framework: theoretical
and practical challenges. Implement Sci 2008; 3: 1.
27. Rogers EM. Diffusions of Innovations, 5th edn. New York: Free
Press, 2003.
28. Flodgren G, Parmelli E, Doumit G et al. Local opinion leaders:
effects on professional practice and health care outcomes.
Cochrane Database Syst Rev 2011; CD000125. doi: 10.1002/
14651858.pub4.
29. Estabrooks CA, Squires JE, Cummings GG, Birdsell JM, Norton
PG. Development and assessment of the Alberta Context Tool.
BMC Health Serv Res 2009; 9: 234.
30. Jamtvedt G, Young JM, Kristoffersen DT, O’Brien MA, Oxman
AD. Audit and feedback: effects on professional practice and
health care outcomes. Cochrane Database Syst Rev 2006;
CD000259. doi: 10.1002/14651858.CD000259.pub2.
31. Inouye SK, Schlesinger MJ, Lydon TJ. Delirium: a symptom of
how hospital care is failing older persons and a window to
improve quality of hospital care. Am J Med 1999; 106: 565–73.
32. Steis MR, Fick DM. Are nurses recognizing delirium? A system-
atic review. J Gerontol Nurs 2008; 34: 41–8.
© 2013 The Authors