pain, agitation, and delirium: bringing it all together peter dodek
TRANSCRIPT
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Pain, Agitation, and Delirium: Bringing it
All TogetherPeter Dodek
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Aim
Measures
Change concepts and specific changes
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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
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Become Familiar with This Document:
Critical Care Medicine. 2013; 41: 263-306.
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Aim: Begin with the End in Mind…
Critical Care Medicine. 2013; 41: 263-306.
-to reduce pain, agitation, and delirium in all ICU patients
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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
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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.
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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.
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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
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Example of Language in a Checklist:ICU Rounds Checklist
HAS THE TEAM DI SCUSSED:
The target RASS
The Delirium Score & management plan
Mobilization Stage
SPH ICU rounds checklist April 2, 2013
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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
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Music Therapy Decreases Pain and Agitation
Jaber S et al. Annales Francaises d’Anesthesie et de Reanimation. 2007
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Music Therapy Decreases Sedation Frequency in Mechanically Ventilated Patients
Chlan LL et al. JAMA 2013
Patient-directed music
Noise-cancelling headphones
Usual care
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Randomized Controlled Trial of PAD protocol
(patient-level, per-protocol analysis)
Mansour P et al. JCC 2013
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Randomized Controlled Trial of PAD protocol
(patient-level, per-protocol analysis)
Mansour P et al. JCC 2013
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Implementing Guidelines for Detection and Treatment of Delirium in a 21-hospital System
Adams CL et al. Clin Nurse Specialist. 2015
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Implementing Guidelines for Detection and Treatment of Delirium in a 21-hospital System
Adams CL et al. Clin Nurse Specialist. 2015
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Amaral ACKB et al. Crit Care 2012
Analysis: Interrupted Time-series vs. Before-after
(intervention: minimizing sedation)
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Uses of RASS: Comparison of Appropriate Responses to RASS
Dodek P et al. BMJ Qual Safety. 2012
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PAD Management and Maslow’s Hierarchy of Needs in Critical Care
Jackson JC et al. JCC 2014
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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
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and