“Pleasantly confused” and missed opportunities for delirium recognition: A hospital record audit

Background Delirium is a serious hospital complication with long-lasting and life-threatening consequences and high healthcare costs. Despite decades of evidence, tools, and guidelines, delirium remains under-recognised and under-treated. Objective To examine alignment between policy and practice for delirium risk identification, screening, and assessment and to identify the language used in documentation to describe cognitive observations and delirium. Design A retrospective, cross-sectional clinical documentation audit using a single-day point prevalence study design. Setting(s) A tertiary metropolitan hospital in southeastern Australia where the clinical records were audited. Participants A midnight census conducted in July 2021 identified 807 inpatient clinical records, of which 460 records met the eligibility criteria for this study. Methods Clinical records were audited for delirium risk identification, screening, assessment, and language use in documentation referring to cognition. Descriptive analyses were used. Results Among the 460 included records, risk factors for delirium were identified in 316 (69%). Of these at-risk patients, only 28/316 (9%) received subsequent screening, and 12/316 (4%) had further assessment, which resulted in 3/316 (1%) having a documented diagnosis of delirium. We also identified 331 documented words and phrases describing cognition. Diagnostic language, such as ‘delirium,’ appeared in only 3% of 331 documented words and phrases. Ambiguous language and euphemisms accounted for 22% of terms and included phrases such as ‘pleasantly confused,’ which dismissed the seriousness and urgency of delirium. Conclusions Despite frequent risk identification, subsequent screening, assessment, and diagnostic naming of delirium was uncommon, creating missed opportunities for recognition and escalation. Ambiguous observations and euphemisms were documented by practitioners and diagnostic language omitted, rendering delirium invisible. Possible opportunities for increasing the detection and visibility of delirium in hospital practice include: nurses using advocacy language, such as ‘possible delirium’ and working diagnoses when screening scores are positive; electronic medical record prompts and alerts when information thresholds are met for patients; streamlined documentation to align everyday practice with delirium care pathway steps; and education alongside a change in institutional culture where cognitive care is seen as fundamental patient care.