Quality Contract: Prevention of Postoperative Delirium in the Care of Older Patients (QV-POD-2)

QV-POD-2: Sustainability of implementation rates (=Number of patients who underwent delirium screening at least twice a day within the first three days postoperatively / Divisor = All recruited patients) of at least 80% for screening and documentation in the next five years.

QV-POD-1: Implementation rates (=Number of patients who underwent delirium screening at least twice a day within the first three days postoperatively / Divisor = All recruited patients) of at least 60% for screening and documentation in the first year, at least 70% in the second year and at least 80% in the third year. Addendum to the primary outcome measures from the ethics amendment vote of 25/07/2022)

QV-POD-2: Sustainability of implementation rates (=Number of patients who underwent delirium screening at least twice a day within the first five days postoperatively / Divisor = All recruited patients) of at least 80% for screening and documentation in the next five years

QV-POD-1: Implementation rates (=Number of patients who underwent delirium screening at least twice a day within the first five days postoperatively / Divisor = All recruited patients) of at least 60% for screening and documentation in the first year, at least 70% in the second year and at least 80% in the third year. Addendum to the secondary outcome measures from the ethics amendment vote of 25/07/2022)

The care level is taken from hospital records preoperatively and postoperatively

Routine laboratory markers

Cholinesterases (point of care testing (POCT) measurements) are measured in the routine

Scale to identify the severity of anticholinergic drugs (Level 0 = no anticholinergic effect, Level 1 = mild anticholinergic effect, Level 2 = moderate anticholinergic effect, Level 3 = severe anticholinergic effect). The sum of all levels of the different drugs gives the total load. Higher total loads of anticholinergic drugs are associated with higher anticholinergic drug load. Minimum of the scale is 0. Maximum depends on the sum of each drug level. The more drugs with anticholinergic effect are taken the higher is the anticholinergic drug load.

Duration of postoperative delirium in all postoperative patients in normal ward, intensive care unit and recovery room is measured in days (a defined day before the start of the training measures, a defined day after the completion of the training measures). Addendum to the secondary outcome measures from the ethics amendment vote of 25/07/2022)

Incidence of postoperative delirium in all postoperative patients in normal ward, intensive care unit and recovery room after validated delirium screening tool at two points in time (a defined day before the start of the training measures, a defined day after the completion of the training measures).

Objective non-invasive EEG is measured intraoperatively

Infections according to surgical site infections (SSI) and according to the US Centers for Disease Control and Preventions (CDC).

Health related quality of life is measured by EQ-5D-5L

The composite outcome measure "PICS" of the patient is measured according to Needham et al 2012: New or worsening physical, cognitive, and/or mental impairments that are collectively called PICS measured by Patient Health Questionnaires (PHQ-4), MiniCog, Animal Naming Test Timed Up-and-Go (TUG), Handgrip strength. The measurements will be performed, when patients present to the outpatient clinic for follow-up examinations.

To evaluate the presence or development of postoperative organ complications during inpatient care

Concomitant pain medication is recorded

Telephone or Video or questionnaire Follow up is offered to every patient with POD three months and one year after their surgery intervention. The aim of Telephone or Video or questionnaire Follow up is to assess to present Neurocognitive disorder (NCD).The Follow up screening tool is based on DSM 5 diagnostic criteria for "mild cognitive disorder". If one of the diagnostic criteria applies, we recommend to visit a neuropsychologist/ memory clinic recommend to visit a neuropsychologist/ memory clinic.

Depression is measured by Patient Health Questionnaire-8 (PHQ-8).This scale encompasses eight questions, which can be answered with not at all (0), several days (1), more than half the days (2) and nearly every day (3). The score is the sum of the 8 items. The minimum score is 0 (best outcome) and the heights 24 (worse outcome).

Anxiety is measured by Generalized Anxiety Disorder Scale-7 (GAD-7).The Assessment method has seven items; each can be answered with not at all (0), several days (1), more than half the days (2) and nearly every day (3). The score is the sum of all items. The minimum and maximum score are 0 (better outcome) and 21 (worse outcome) respectively.

Physical health is measured by the sum scores of the following outcome measurement instruments: Timed Up-and-Go (TUG), Handgrip Strength, 2-Minute Walk Test (2-MWT), Short Physical Performance Battery (SPPB).

Intensive care unit length of stay is measured in days

Hospital length of stay is measured in days

Pain levels 1 are measured with Numeric Rating Scale (NRS). NRS scale's range from 0 to 10. 0: no pain; 1-3: light pain; 4-6: moderate pain; 7-10: severe pain.

Pain levels 2 are measured with Visual Analog Scale (VAS). VAS scale's range from 0 to 10. 0: no pain; 1-3: light pain; 4-6: moderate pain; 7-10: severe pain.

Pain levels 3 are measured with Assessment of pain in dementia (BESD). BESD: The focus of external observation is on the following behavioral patterns: breathing, negative vocalization, facial expression, body language, and comfort in relation to exertional pain. Observed behaviors are assigned a score from 0 to 2. The range of the score is between 0 and 10, with 10 points indicating the most pronounced pain behavior.

Pain levels 4 are measured through the use of a scale based on behaviour items, the Behavioural Pain Scale (BPS). BPS scale's range from 3 to 12; 3: no pain, high number more pain.

Pain levels 5 are measured through the use of a scale based on behaviour items, the Behavioural Pain Scale - non-intubated (BPS-NI). BPS-NI scale's range from 3 to 12; 3: no pain, high number more pain. In the BPS-NI, the BPS item "Adaptation to the Ventilator" has been replaced by "Vocalization." The BPS-NI can be used, for example, to determine pain status in conscious, delirious patients.

Disability 1 is measured by Instrumental activities of daily living scale.This scale has 8 categories (ability to use telephone, shopping, food preparation, housekeeping, laundry, mode of transportation, responsibility for own medications, ability to handle finances). Each has different levels of functioning with a score assigned. The patient circles the item that most closely describes its functional level. The lowest score is 0 (better outcome) and the highest is 8 (worse outcome).

Disability 2 is measured by Timed up and go test.

Disability 3 is measured by hand grip strength test

Faces Anxiety Scale score

Sedation is measured with the Richmond Agitation and Sedation Scale (RASS)

The Glasgow Coma Scale (GCS) is a clinical scale used to reliably measure a person's level of consciousness after a brain injury. The GCS assesses a person based on their ability to perform eye movements, speak, and move their body. These three behaviors make up the three elements of the scale: eye, verbal, and motor. A person's GCS score can range from 3 (completely unresponsive) to 15 (responsive). This score is used to guide immediate medical care after a brain injury (such as a car accident) and also to monitor hospitalized patients and track their level of consciousness.

Lower GCS scores are correlated with higher risk of death.

Medication at three months compared to baseline is assessed.

Frequency of frailty is measured by modified Fried criteria (category 1 +2 = pre-frail, category 3 -5 = frail)

Ingestion is measured by the amount of fluids and solid food.

Score of the Barthel Index ranging from 0 to 100 were collected when 0 is the minimum (worst outcome) and 100 is the maximum (best outcome).

Score was reported as mean score of the Barthel Index.

Different tools and questionnaires are combined to measure Patient-related outcome.

Patient-reported experiences of health care are measured with a questionnaire.

Therapy recommendations are documented from patient records.

Survival is measured in Patients form QV-POD-2 within 1 year; Survival is measured in patients from QV-POD-1 until 3 months (addendum to the secondary outcome measures from the ethics amendment vote of 28/08/2025) and in patients from QV-POD-2 as Interim analysis of 3-month mortality among QV-POD-2 patients from the recruitment period: July 1, 2023 - December 1, 2025, and then annually in December until the end of the study.

Continous patient monitoring of physiological data - measured by CardioWatch 287-2 during hospital stay.

Preoperative routine data are medical history, diagnoses, medication, etc.

Patient-specific characteristics of patients with delirium

Development of a risk model with different influencing factors of delirium