Evaluation of the management of pain, agitation, and delirium in the

Abstract Presentation Number: 214
Platform Presentation Category:
Critical Care
Evaluation of the management of
pain, agitation, and delirium in
the intensive care unit
Shannon Hatzell, PGY1 Resident
Bozeman Deaconess Hospital
IRB Status: Not Needed
Disclosure Statement
Shannon Hatzell, PharmD
• Potential conflicts of interest: None
• Sponsorship: None
• Proprietary information or results of
ongoing ongoing research may be subject
to different interpretations.
• Presentation of this slide indicates my
agreement to abide by the noncommercialism guidelines provided on the
CE Requirements page.
Learning Objective
• Describe a method to evaluate
assessment practices for pain, agitation,
and delirium in ICU patients
Bozeman Deaconess Health
Services
• 89 bed hospital
• 24 hour pharmacy services
• Services:
– 8-bed ICU
– PCU
– Medical floor
– Surgical floor
– Level III Trauma Center
– Outpatient medical and specialty clinics
Project Background
• The American College of Critical Care Medicine
developed guidelines for the management of
pain, agitation, and delirium in adult patients in
the ICU.
• Improved patient outcomes are associated with
ensuring patient comfort while maintaining a
light level of sedation.
• Pain and physical discomfort are frequently
experienced by patients in the ICU
• Delirium is becoming increasingly recognized as
a major problem in critically ill patients.
Research Background
• Evaluate current practices of assessing, monitoring and
managing pain, agitation, sedation, and delirium in the
ICU
• Propose recommendations to develop/improve protocols
for monitoring, preventing, and treating pain, agitation,
sedation, and delirium in the ICU
• Educate ICU patient care staff on the protocols and data
to support the protocols
• Evaluate the effect of the new protocols on ICU length of
stay, hospital length of stay, number of mechanical
ventilation days, and number of self-extubations
Research Methodology
• This study was not submitted to an Institutional
Review Board for approval. This study is
approved by the Pharmacy and Therapeutics
Committee at Bozeman Deaconess Hospital.
• This study includes patients 18 years of age and
older who are mechanically ventilated in the
intensive care unit. A retrospective review, using
the electronic medical record, was conducted for
patients who were ventilated from April 1, 2013
to September 30, 2013.
Research Methodology Continued
• Another data collection period will be completed
after implementation of a protocol for managing
pain, agitation, and delirium in the ICU at BDH.
• Intensive care length of stay, hospital length of
stay, duration of mechanical ventilation, and the
number of self-extubations will be recorded
during each data collection period. These
outcomes will be used to compare our facility’s
current management strategies used in the
hospital to the American College of Critical Care
Medicine guidelines for the management of pain,
agitation, and delirium.
Retrospective Data
• Number of patients included in the
retrospective data analysis: 60 patients
• Total number of ventilation days that were
analyzed: 327 total ventilation days
• Electronic medical records were reviewed
to analyze pain and agitation assessments
for each day a patient was mechanically
ventilated
Retrospective Data Continued
Retrospective Data Continued
Current Pain Assessment and
Monitoring at BDH
• Pain should be assessed once every shift
• Assessment should be completed with NRS,
FLACC, or Wong-Baker Faces
• Document pain assessment in one of three
locations
• If an intervention is made a reassessment must
be completed within one hour
• If an intravenous medication is administered a
reassessment must be completed within 30
minutes.
Pain Assessment
Number of Times Pain Assessed in a 24 Hour Period
8x's 0.7%
9x's 0.7%
10x's 0.7%
11x's 0.7%
7x's 0.7%
6x's
5.0%
7.1%
0
5x's 9.2%
1
1x's 15.6%
2
3
4
5
4x's 17.0%
6
7
2x's 17.7%
8
9
10
11
3x's 24.8%
Pain Assessment
Pain Scale Used for Assessment
8%
11%
3%
No Scale
NRS
FLACC
Wong Baker Faces
78%
Recommendations for
Improvement at BDH
• Assess pain every four hours and as needed
• Implement the Critical Care Pain Observation Tool
(CPOT) to assess pain in mechanically ventilated
patients
• Identify types of pain and appropriate treatments
• Treat pain within thirty minutes and then reassess
• Administer pain medications before painful procedures
• Education
– CPOT
– Treat pain before sedating patient
– Importance of documentation
Next Steps for Pain Management
• Present current literature to the ICU
committee in an attempt to implement the
CPOT pain assessment scale.
• If the CPOT is approved, education will be
provided to the nursing staff on how to
effectively assess pain using the CPOT.
Sedation Assessment and
Monitoring at BDH
• A ventilator management assessment
must be completed every four hours
– RASS score
– Ventilator settings
– PUD prophylaxis
– DVT prophylaxis
– Suctioning
Breakdown of RASS Scores
RASS=1
RASS=2 2%
RASS=3
4.3%
0.3%
RASS=0 1%
RASS=-5 7.2%
RASS=-1 8.3%
RASS=-2
31.0%
RASS=-4 7.9%
RASS=-3
38.5%
-5
-4
-3
-2
-1
0
1
2
3
Recommendations for
Improvement at BDH
• Encourage physicians to write a target
sedation level with each mechanical
ventilation order
• Education
– Benefits of a light level of sedation
– Look for reasons why a patient is agitated
before increasing sedation medications
– RASS scores
Approach to Delirium at BDH
• EDUCATION
– Why should we assess for delirium?
– How do we assess for delirium?
– What causes delirium?
– How do we prevent delirium?
– What are our treatment options for delirium?
• Implement the Confusion Assessment
Method (CAM-ICU) Protocol
Delirium Protocol
• A group of three nurses, a nursing educator, and
pharmacy resident are working together on
implementing a delirium protocol for the ICU.
• After reviewing current literature the group
decided that the CAM-ICU was the assessment
scale that they wanted to use in the ICU.
• A literature review was presented to ICU
committee which approved the implementation of
the CAM-ICU with appropriate education being
given to nursing staff and physicians.
Next Steps to Implement the
CAM-ICU
• Education will be provided to the nursing
staff on how to properly use the CAM-ICU
• Education will be provided to the
physicians on how to interpret the
CAM-ICU results, management of
delirium, and treatment options for
delirium.
• Develop order sets
• Implement
Follow-Up Study
• A follow-up study will be completed to see
if there was improvement in hospital length
of stay, ICU length of stay, days of
mechanical ventilation, and number of
self-extubations.
Assessment Questions
1. CAM-ICU is a validated scale for assessing delirium in mechanically
ventilated patients. True or False?
2. What is the most valid and reliable pain scale for monitoring pain in
adult ICU patients who are unable to self-report but who have motor
function that is intact and behaviors that are observable?
a.
FLACC
b.
Wong-Baker Faces
c.
Numeric Rating Scale
d.
Critical-Care Pain Observation Tool (CPOT)
Answers to Questions
• 1. True. The CAM-ICU is a validated tool
for assessing delirium in the ICU.
• 2. D. The CPOT is the most valid and
reliable pain scale for assessing pain in
adult ICU patients who are unable to selfreport but who have motor function that is
intact and behaviors that are observable.
References
•
•
Barr J, Fraser GL, Puntillo K, et al. Clinical
practice guidelines for the management of
pain, agitation, and delirium in adult patients in
the intensive care unit. Crit care
2013;14(1):263-306.
Barr J, Pandharipande PP. The pain, agitation,
and delirium care bundle: synergistic benefits
of implementing the 2013 pain, agitation, and
delirium guidelines in an integrated and
interdisciplinary fashion. Crit care
2013:41(9):99-115.

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