Delirium risk factor screening and preventative protocol

This measure uses the following formulae to identify quality of care performance.

Measure purpose: Reduce the likelihood of longer inpatient treatment and increased treatment cost

The numerator: high risk patients who had a preventative protocol instituted

is divided by

The denominator: all patients >18 years of age who are at high risk of developing delirium 

Exclusions are removed from the denominator for:

• Diagnosis of delirium at time of, or prior to, admission
• Patient or family/caregiver refuses preventative protocol
• Unable to institute protocol for medical reasons

 Key Phrases

Key phrases you should document to meet the measure include:

• High-risk for delirium
• Delirium risk
• Delirium protocol implemented/instituted

Measure Calculation Example

Dr. Smith has 100 patients between January 1 and December 31 of the measurement year that were admitted to her inpatient service. 15 of them were under the age of 18. Of the remaining 85 patients, 56 of them were considered to be at high risk* for developing delirium. 

Of the 56 patients considered to be at high risk for developing delirium, 7 patients should be removed from the denominator due to having a diagnosis of delirium at the time of or prior to admission, or the patient and/or family refused the preventative protocol, or the preventative protocol was unable to be instituted for medical reasons.

Of the now 49 patients that still qualify for this measure, 19 of them had a preventative protocol instituted.

Quality of patient care = 19/(56-7). Dr. Smith has a score of 38% for this measure.