Presentation on theme: "Juliana Barr, MD, FCCM Chair, ACCM PAD Guideline Task Force"— Presentation transcript:
1 ICU Pain, Agitation, & Delirium Care Bundle Metrics: Measurement for Improvement Juliana Barr, MD, FCCMChair, ACCM PAD Guideline Task ForceAssociate Professor of Anesthesia,Stanford University School of MedicineAssociate ICU Medical Director,VA Palo Alto Health Care System
2 No Commercial Affiliations.... COI DisclosuresNo Commercial Affiliations....
3 Learning ObjectivesTo become familiar with the elements of the ICU PAD Care Bundle.To understand the synergistic benefits of applying the ICU PAD Care Bundle elements in an integrated fashion.To learn how to implement the ICU PAD Care Bundle.To learn how to monitor the effectiveness of the ICU PAD Care Bundle.3
4 Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit Authors: Juliana Barr, MD, FCCM; Gilles L. Fraser, PharmD, FCCM; Kathleen Puntillo, RN, DNSc, FAAN; E. Wesley Ely, MD, MPH, FACP, FCCM; Céline Gélinas, RN, PhD; Joseph F. Dasta, MSc; Judy E. Davidson, DNP, RN; John W. Devlin, PharmD, FCCM; John P. Kress, MD; Aaron M. Joffe, DO; Douglas B. Coursin, MD; Daniel L. Herr, MD, MS, FCCM; Avery Tung, MD; Bryce RH Robinson, MD, FACS; Dorrie K. Fontaine, PhD, RN, FAAN; Michael A. Ramsay, MD; Richard R. Riker, MD, FCCM; Curtis N. Sessler, MD, FCCP, FCCM; Brenda Pun, RN, MSN, ACNP; Yoanna Skrobik, MD, FRCP; Roman Jaeschke, MD, MScCritical Care Medicine (In press)
5 2012 Pain, Agitation, and Delirium Clinical Practice Guidelines Why are they significant?
6 Deep vs. Light Sedation of ICU Patients XDeep vs. Light Sedation of ICU PatientsPre-PAD GuidelinesPost-PAD Guidelines
8 The Path to PAD Integration… PAD Care Bundle* *Pain, Agitation, and Delirium Care Bundle
9 The Path to PAD Integration (cont.) SAT/TSSBTABCMV ↓ 3dLOS ↓ 4dMort ↓ 32%ABCEMABC+EICU LOS ↓ 1.4dHosp LOS ↓ 3.3dSAT/TSEMABCDE↓ delirium↑ d/c
10 Expected Benefits of Implementing the PAD Guidelines Shortened duration of MVReduced ICU, hospital LOSIncreased ICU patient throughput, bed availabilityDecreased costs per patientImproved long-term cognitive function, mobilityIncreased number of patients discharged to home!Lives saved!
11 Implementing the ICU PAD Care Bundle PAINAGITATIONDELIRIUMAssess pain ≥ 4x/shift & prnPreferred pain assessment tools:Patient able to self-report NRS (0-10)Unable to self-report BPS (3-12) or CPOT (0-8)Patient is in significant pain if NRS ≥ 4, BPS ≥ 6, or CPOT ≥ 3Assess agitation, sedation ≥ 4x/shift & prnPreferred sedation assessment tools:RASS (-5 to +4) or SAS (1 to 7)NMB suggest using brain function monitoringDepth of agitation, sedation defined as:agitated if RASS = +1 to +4, or SAS = 5 to 7awake and calm if RASS = 0, or SAS = 4lightly sedated if RASS = -1 to -2, or SAS = 3deeply sedated if RASS = -3 to -5, or SAS = 1 to 2Assess delirium Q shift & prnPreferred delirium assessment tools:CAM-ICU (+ or -)ICDSC (0 to 8)Delirium present if:CAM-ICU is positiveICDSC ≥ 4ASSESSTreat pain within 30” then reassess:Non-pharmacologic treatment– relaxation therapyPharmacologic treatment:Non-neuropathic pain IV opioids +/- non-opioid analgesicsNeuropathic pain gabapentin or carbamazepine, + IV opioidsS/p AAA repair, rib fractures thoracic epiduralTargeted sedation or DSI (Goal: patient purposely follows commands without agitation): RASS = -2 – 0, SAS = 3 - 4If under sedated (RASS >0, SAS >4) assess/treat pain treat w/sedatives prn (non-benzodiazepines preferred, unless ETOH or benzodiazepine withdrawal suspected)If over sedated (RASS <-2, SAS <3) hold sedatives target, then 50% of previous doseTreat pain as neededReorient patients; familiarize surroundings; use patient’s eyeglasses, hearing aids if neededPharmacologic treatment of delirium:Avoid benzodiazepines unless ETOH or benzodiazepine withdrawal suspectedAvoid rivastigmineAvoid antipsychotics if risk of Torsades de pointesTREATLegend:IPAD Care Bundle = ICU Pain, Agitation, and Delirium Care BundleNRS = Numeric Rating ScaleBPS = Behavioral Pain ScaleCPOT = Critical-Care Pain Observation ToolNon-pharmacologic therapy = relaxation therapy, especially for chest tube removalIV = intravenousAAA = abdominal aortic aneurysmNMB = neuromuscular blockadeRASS = Richmond Agitation and Sedation ScaleSAS = Sedation Agitation ScaleBrain Function Monitoring = auditory evoked potentials [AEP], Bispectral Index [BIS], Narcotrend Index [NI], Patient State Index [PSI], or state entropy [SE]DSI = daily sedation interruption (also referred to as SAT = spontaneous awakening trial)ETOH = ethanolNon-benzodiazepines = propofol (use in intubated/mechanically ventilated patients), dexmedetomidine (use in either intubated or non-intubated patients).SBT = spontaneous breathing trialEEG = electroencephalographyICP = intracranial pressureCAM-ICU = Confusion Assessment Method for the ICUICDSC = ICU Delirium Screening ChecklistAdminister pre-procedural analgesia and/or non-pharmacologic interventions (eg, relaxation therapy)Treat pain first, then sedateConsider daily SBT, early mobility and exercise when patients are at goal sedation level, unless contraindicatedEEG monitoring if:at risk for seizuresburst suppression therapy is indicated for ICPIdentify delirium risk factors: dementia, HTN, ETOH abuse, high severity of illness, coma, benzodiazepine administrationAvoid benzodiazepine use in those at risk for deliriumMobilize and exercise patients earlyPromote sleep (control light, noise; cluster patient care activities; decrease nocturnal stimuli)Restart baseline psychiatric meds, if indicatedPREVENT
12 Challenges to Implementing the ICU PAD Care Bundle PAD AssessmentPADTreatmentPreventionPAD IntegrationCompliance
13 Step 1: Implement Pain, Agitation, and Delirium Monitoring Tools in the ICU AnxietyDelirium
20 Delirium Assessment Intensive Care Delirium Screening Checklist Delirium Assessment Intensive Care Delirium Screening Checklist* (ICDSC)*Delirium present if ICDSC > 4
21 Step 2: Incorporate PAD Assessments into Daily ICU Care Plan What is the patient’s pain score and their current analgesia regimen?What is the patient’s current and target sedation scores, and their current sedation regimen?What is the patient’s delirium score and what are their delirium risk factors?
22 Step 3: Apply ICU Specific Pain, Agitation, and Delirium Management Protocols Assess and treat pain first, then sedate (analgo-sedation)Treat significant pain: NRS ≥ 4, BPS ≥ 6, or CPOT ≥ 3Use appropriate pain management strategies (patient specific)Administer pre-procedural analgesiaAgitation/Sedation:Minimize sedative use, avoid over-sedation (DSI or TSS→SAT)Sedation goals: patient is responsive, aware, and able to purposely follow commands* (RASS = 0 to -2 or SAS = 3 to 4)Choose sedatives that minimize side effects (patient-specific)Delirium:Optimize pain managementReorient patientD/C deliriogenic drugsTreat with anti-psychotics (patient-specific)*Performs 3 out of 5 commands: opens eyes, maintains eye contact, squeezes hand, sticks out tongue, wiggles toes.
23 Step 4: Link to Other Strategies to Reduce the Need for Medications, Improve Outcomes Link spontaneous awakening trials (SAT) to spontaneous breathing trials (SBT)-facilitate weaning from MV.Link SAT to early mobility and exercise (EM) protocols-reduce delirium, improve strength.Implement environmental controls to protect patients’ sleep-wake cycles-reduce delirium, improve sleep.
24 PAD Interdisciplinary Team Integrated Approach to PADMD ChampionRN ChampionRT ChampionPharmacy ChampionPhysical Therapy ChampionHospital AdministratorsFamilyPatient
25 PAD Guideline Implementation MD Champion!PAD Implementation (%)Interdisciplinary PADStakeholder Team
26 ICU PAD Care Bundle Implementation Using PDSA Cycles PLANDOSTUDYACT
27 ICU PAD Care Bundle Implementation Using PDSA Cycles Plan:Assume your plan is flawed from the beginning!Set expectations, solicit feedback from stakeholders (get provider buy in).Do:Test drive individual components on a small scale (pick the right environment).Try something out quickly over short period (i.e., 1 shift, 1 day, 1 week).Study:Collect data to measure compliance with your intervention (sample small amounts on a frequent basis).Get feedback from beta-testers (what went well, what didn’t, and why?)Act:Use data to improve your process (i.e., iterative improvement).Share results with all stakeholders-post run charts of process, outcome measures over time (↑transparency, buy-in).Retest and expand use when process is working!
28 ICU PAD Care Bundle Measuring Performance How do you know if your ICU PAD Protocols are working?
29 ICU PAD Care Bundle − Metrics PAINAGITATIONDELIRIUM% of time patients are monitored for pain ≥ 4x/shiftDemonstrate local compliance and implementation integrity over time in the use of ICU pain scoring systems% of time sedation assessments are performed ≥ 4x/shiftDemonstrate local compliance and implementation integrity over time in the use of ICU sedation scoring systems% of time delirium assessments are performed QshiftDemonstrate local compliance and implementation integrity over time in the use of ICU delirium assessment toolsASSESS% of time ICU patients are in significant pain (ie, NRS ≥ 4, BPS ≥ 6, or CPOT ≥ 3)% of time pain treatment is initiated within 30” of detecting significant pain% of time patients are either optimally sedated or successfully achieve target sedation during DSI trials (ie, RASS = -2 – 0, SAS = 3 – 4)% of time ICU patients are under sedated (RASS > 0, SAS > 4)% of time ICU patients are either over sedated (non-therapeutic coma, RASS <-2, SAS < 3) or fail to undergo DSI trials% of time delirium is present in ICU patients (CAM-ICU is positive or ICDSC ≥ 4)% of time benzodiazepines are administered to patients with documented delirium (not due to ETOH or benzodiazepine withdrawal)TREATLegend:NRS = Numeric Rating ScaleBPS = Behavioral Pain ScaleCPOT = Critical-Care Pain Observation ToolRASS = Richmond Agitation and Sedation ScaleSAS = Sedation Agitation ScaleETOH = ethanolDSI = daily sedation interruptionSBT = spontaneous breathing trialEEG = electroencephalographyICP = intracranial pressureCAM-ICU = Confusion Assessment Method for the ICUICDSC = ICU Delirium Screening ChecklistNOTE: Consider monitoring impact of IPAD Care Bundle on overall outcome measures, such as:1) Mechanical Ventilation: ventilator-free time (mean and per patient); duration of mechanical ventilation (mean and per patient); and days of mechanical ventilation per 1000 ICU patient days.2) Length of stay: ICU LOS, hospital LOS3) Mortality: ICU, hospital4) Functional status: at ICU discharge, hospital discharge, and post discharge.5) ICU Device-related Infection Rates: VAP, CLAB, UTI% of time patients receive pre-procedural analgesia therapy and/or non-pharmacologic interventions% compliance with institutional-specific ICU pain management protocols% failed attempts at SBTs due to either over or under sedation% of patients undergoing EEG monitoring if:at risk for seizuresburst suppression therapy is indicated for ICP% compliance with institutional-specific ICU sedation/agitation management protocols% of patients receiving daily physical therapy and early mobility% compliance with ICU sleep promotion strategies% compliance with institutional-specific ICU delirium prevention and treatment protocolsPREVENT
30 ICU PAD Care Bundle Measuring Performance Process vs. Outcome Measures*:Process:Are you doing what you think you’re doing?Identify a process measure for each aspect of your protocol that you’re going to implement.Outcome:Is what you’re doing achieving the desired outcome?Measure both good and bad outcomes.*Measure and chart all process and outcome measures at baseline and over time.
31 ICU PAD Care Bundle Measuring Performance-Pain Management Process measures:Measure frequency of NRS (self-report) or BPS/CPOT assessments (self-report NA) (i.e., Q1-2 hr or less?).Measure inter-rater reliability with BPS/CPOT assessments (i.e., compare bedside nursing assessments to nurse educator assessments-use real or mock patients).Measure % time patients receive analgesics within 30” of identifying significant pain.Measure % of time patients receive pre-procedural analgesics.Outcome measures:Measure % time patients are in significant pain (NRS > 4 or BPS > 6/CPOT > 3).Measure analgesic use in the ICU (↑ or ↓).
32 ICU PAD Care Bundle Measuring Performance-Sedation Management Process measures:Measure frequency of RASS/SASS assessments (i.e., Q1-2 hr or less?).Measure inter-rater reliability with RASS/SAS assessments (i.e., compare bedside nursing assessments to nurse educator assessments-use real or mock patients)% of time patients are either optimally sedated or successfully achieve target sedation levels during DSI trials (i.e, RASS = -2 – 0, SAS = 3 – 4)Outcome measures:Overall incidence of light sedation of ICU patients over time ( or remains unchanged?).% failed attempts at SBTs, Early Mobility trials due to either over or under sedationMeasure sedative use in the ICU (↓ or no change?).
33 ICU PAD Care Bundle Measuring Performance-Delirium Management Process measures:Frequency of CAM-ICU/ICDSC assessments (i.e., Qshift or less?).Inter-rater reliability with CAM-ICU/ICDSC assessments (i.e., compare bedside nursing assessments to nurse educator assessments-use real or mock patients).% of time delirium is present in ICU patients (i.e., CAM-ICU is positive or ICDSC ≥ 4).Types of sedatives used in delirious ICU patients (i.e., benzos vs. non-benzos?).% of ICU patients receiving daily physical therapy, early mobility.% compliance with ICU sleep promotion strategies.Outcome measures:Overall incidence/prevalence and duration of delirium in ICU patients over time.
34 ICU PAD Bundle Toolkit Web-based Educational Tools: PowerPoint presentations−PAD guideline staff educationInstructional videosBedside pain, sedation/agitation, and delirium assessmentsEarly mobility techniquesImplementation Tools:Pocket cards−ICU PAD Care bundle, guideline recommendationsApps for smart phone, tablets-monitoring tools, drug dosing guidelinesTemplates-check lists, goals sheetsSample protocols
35 Implementing the PAD Guidelines Key Points Routinely assess pain, sedation/agitation, and delirium separately using validated tools.Avoid deep sedation, let patients be interactive.Integrate PAD management with SBT, Early Mobility, Environmental Sleep Management.Implement the PAD Care Bundle using an interdisciplinary, team-based approach.Measure what you’re doing, improve performance!