Pain, Agitation, and Delirium: Bringing it All Together

Peter Dodek

Aim

Measures

Change concepts and specific changes

Who Should be Involved?

• Bedside nurses

• Nurse Educators

• Physicians—attending and house-staff

• Respiratory Therapists

• Leaders--nurse, physician, RT

• Pharmacists

• Physiotherapists

• Music therapists

• Patients, family members

Become Familiar with This Document:

Critical Care Medicine. 2013; 41: 263-306.

Aim: Begin with the End in Mind…

Critical Care Medicine. 2013; 41: 263-306.

-to reduce pain, agitation, and delirium in all ICU patients

Potential Measures:

• Patient:• Average RASS• Delta RASS (Target minus Actual)• Average pain score• Delirium-free days alive (normalized to duration of stay)• Unplanned extubation

• Family:• Perceptions of pain, agitation, delirium that the patient is experiencing

• Staff:• Attitudes to sedation protocol• Knowledge of PAD practices• Compliance with daily target and screening

• ICU:• Amount of sedatives, analgesics, and anti-psychotics used

Facilitators and Barriers(to implementation of the ABCDE bundle)

• Facilitators:• Daily, interdisciplinary rounds

• Engagement of key implementation leaders

• Sustained and diverse educational interventions

• Quality and strength of recommendations

• Barriers:• Timing of

awakening/breathing trials, fear of adverse events

• Communication and care coordination issues

• Knowledge deficits

• Workload concerns

• Documentation burden

Balas MC et al. Crit Care Med. 2013.

Implementing the Guidelines--Top Ten Points

• Understand the prescriptive nature of the guidelines—strategy vs. specific medications

• Gap analysis (what are you already doing), ‘elevator speech’

• Focus on inter-professional work

• Start with assessment of pain, agitation, and delirium

• Intense, sustained professional education—eg. checklists

• Focus on light sedation

• Consider non-benzodiazepine strategies

• Expect ‘confusion’ regarding role of antipsychotics

• Use non-pharmacological approaches

• Mobilize patients early and often

Pun BT. Sem Resp CCM 2013.

Some other ‘quick wins’

• Make documentation easier• put RASS and Delirium scores in a prominent location on the

flowsheet

• Prevention• pre-emptive analgesia (before procedures)

• optimize sleep-wake cycles

• Raise awareness• Posters, in-services, intranet, social media

• Daily rounds checklist

Example of Language in a Checklist:

ICU Rounds Checklist

HAS THE TEAM DISCUSSED:

The target RASS

The Delirium Score & management plan

Mobilization Stage

SPH ICU rounds checklist April 2, 2013

QI approach is associated with decreasing pain and adverse events while moving ICU patients

de Jong et al. Crit Care 2013.

Success factors:1. Culture of ICU2. Multi-disciplinary3. Evidence-based

Music Therapy Decreases Pain and Agitation

Jaber S et al. Annales Francaises d’Anesthesie et de Reanimation. 2007

Music Therapy Decreases Sedation Frequency in Mechanically Ventilated Patients

Chlan LL et al. JAMA 2013

Patient-directed music

Noise-cancelling headphones

Usual care

Randomized Controlled Trial of PAD protocol(patient-level, per-protocol analysis)

Mansour P et al. JCC 2013

Randomized Controlled Trial of PAD protocol(patient-level, per-protocol analysis)

Mansour P et al. JCC 2013

Implementing Guidelines for Detection and Treatment of Delirium in a 21-hospital System

Adams CL et al. Clin Nurse Specialist. 2015

Implementing Guidelines for Detection and Treatment of Delirium in a 21-hospital System

Adams CL et al. Clin Nurse Specialist. 2015

Amaral ACKB et al. Crit Care 2012

Analysis: Interrupted Time-series vs. Before-after(intervention: minimizing sedation)

Uses of RASS: Comparison of Appropriate Responses to RASS

Dodek P et al. BMJ Qual Safety. 2012

PAD Management and Maslow’s Hierarchy of Needs in Critical Care

Jackson JC et al. JCC 2014

Summary

• Engage the key stakeholders

• Study the guidelines

• Develop an aim

• Establish key process and outcome measures

• Find out what you are already doing and what you need to do

• Think prevention

• Remember the barriers—don’t try to do too much at once

• Share findings with everyone in the ICU—solicit ideas for next steps

and