- Design
- Pragmatic randomised controlled trial embedded in routine care, single centre
- Population
- 7,294 surgical patients with preoperative cognitive impairment
- Primary outcome
- Postoperative delirium (4AT) within 7 days
- Effect
- 35.1% vs 32.7% (P = 0.37); no change in best-practice adherence
In a pragmatic trial at one New York hospital, 7,294 surgical patients identified as cognitively impaired, by a language-processing algorithm, cognitive scores or diagnosis codes, were randomised to usual care or a non-interruptive prompt in the electronic record encouraging anaesthesia teams to follow delirium-prevention best practices.
Only 1,255 patients (17%) had a documented delirium assessment, and about a third of those had delirium. Delirium rates did not differ between groups (35.1% vs 32.7%), and adherence to 12 best practices did not change either.
The low assessment rate means the trial cannot say whether the prompt affected delirium. The clearer finding is that a passive, non-interruptive prompt did not change what clinicians did.
Two lessons follow: delirium is not measured if routine screening is patchy, and identifying high-risk patients is only useful if it is linked to an action someone is expected to take.
- Screen for postoperative delirium routinely with a validated tool such as the 4AT.
- Do not rely on passive electronic prompts to change perioperative practice.
- Link identification of cognitive impairment to a specific prevention bundle.
- Assign responsibility for delirium prevention steps explicitly.
Why it matters
It shows that flagging risk in the record is not the same as changing what happens to the patient.
Don't overread it
With delirium assessed in fewer than one in five patients, the trial cannot rule out an effect on delirium.
The statistics, in plain English
35.1% against 32.7% is not a meaningful difference (P = 0.37). Because 83% of patients were never assessed, the delirium comparison is unreliable and could hide a real effect in either direction.
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