PAD Launch Day - Peter Dodek

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<p>PowerPoint Presentation</p> <p>Pain, Agitation, and Delirium: Bringing it All TogetherPeter Dodek</p> <p>AimMeasuresChange concepts and specific changesWho Should be Involved?Bedside nursesNurse EducatorsPhysiciansattending and house-staffRespiratory TherapistsLeaders--nurse, physician, RTPharmacistsPhysiotherapistsMusic therapistsPatients, family membersBecome Familiar with This Document:</p> <p>Critical Care Medicine. 2013; 41: 263-306.Aim: Begin with the End in Mind</p> <p>Critical Care Medicine. 2013; 41: 263-306.-to reduce pain, agitation, and delirium in all ICU patientsPotential Measures:Patient:Average RASSDelta RASS (Target minus Actual)Average pain scoreDelirium-free days alive (normalized to duration of stay)Unplanned extubationFamily:Perceptions of pain, agitation, delirium that the patient is experiencingStaff:Attitudes to sedation protocolKnowledge of PAD practicesCompliance with daily target and screeningICU:Amount of sedatives, analgesics, and anti-psychotics usedFacilitators and Barriers(to implementation of the ABCDE bundle)Facilitators:Daily, interdisciplinary roundsEngagement of key implementation leadersSustained and diverse educational interventionsQuality and strength of recommendations</p> <p>Barriers:Timing of awakening/breathing trials, fear of adverse eventsCommunication and care coordination issuesKnowledge deficitsWorkload concernsDocumentation burdenBalas MC et al. Crit Care Med. 2013.Implementing the Guidelines--Top Ten PointsUnderstand the prescriptive nature of the guidelinesstrategy vs. specific medicationsGap analysis (what are you already doing), elevator speechFocus on inter-professional workStart with assessment of pain, agitation, and deliriumIntense, sustained professional educationeg. checklists</p> <p>Focus on light sedationConsider non-benzodiazepine strategiesExpect confusion regarding role of antipsychoticsUse non-pharmacological approachesMobilize patients early and oftenPun BT. Sem Resp CCM 2013.Some other quick winsMake documentation easierput RASS and Delirium scores in a prominent location on the flowsheetPreventionpre-emptive analgesia (before procedures)optimize sleep-wake cyclesRaise awarenessPosters, in-services, intranet, social mediaDaily rounds checklistExample of Language in a Checklist:</p> <p>SPH ICU rounds checklist April 2, 2013QI approach is associated with decreasing pain and adverse events while moving ICU patients</p> <p>de Jong et al. Crit Care 2013.Success factors:Culture of ICUMulti-disciplinaryEvidence-basedMusic Therapy Decreases Pain and Agitation</p> <p>Jaber S et al. Annales Francaises dAnesthesie et de Reanimation. 2007Music Therapy Decreases Sedation Frequency in Mechanically Ventilated Patients</p> <p>Chlan LL et al. JAMA 2013Patient-directed musicNoise-cancelling headphonesUsual careRandomized Controlled Trial of PAD protocol(patient-level, per-protocol analysis)</p> <p>Mansour P et al. JCC 2013</p> <p>Randomized Controlled Trial of PAD protocol(patient-level, per-protocol analysis)</p> <p>Mansour P et al. JCC 2013Implementing Guidelines for Detection and Treatment of Delirium in a 21-hospital System</p> <p>Adams CL et al. Clin Nurse Specialist. 2015Implementing Guidelines for Detection and Treatment of Delirium in a 21-hospital System</p> <p>Adams CL et al. Clin Nurse Specialist. 2015</p> <p>Amaral ACKB et al. Crit Care 2012Analysis: Interrupted Time-series vs. Before-after(intervention: minimizing sedation)Uses of RASS: Comparison of Appropriate Responses to RASS</p> <p>Dodek P et al. BMJ Qual Safety. 2012</p> <p>PAD Management and Maslows Hierarchy of Needs in Critical CareJackson JC et al. JCC 2014SummaryEngage the key stakeholdersStudy the guidelinesDevelop an aimEstablish key process and outcome measuresFind out what you are already doing and what you need to doThink preventionRemember the barriersdont try to do too much at onceShare findings with everyone in the ICUsolicit ideas for next steps</p> <p>and </p>