1. Multidisciplinary Approach to Sedation Goals and Treatment Algorithms to Treat Pain & Sedation Needs of PCTU Patients Connie Myres RN, MSN, CCRN & Sandra Merkel, MS, RN-BC Regine L. Caruthers, Pharm.D. & Robert Gajarski Jr, MD EDUCATION Assessment of pain, sedation, agitation and withdrawal using current evidenced based practice tools utilizing an education module provided by the pediatric pain service of Mott. SEDATION GOALS Implement through a joint process with physicians, nursing and pharmacy to have all care providers using the same language to describe the intended care. THE GOALS OF THIS RESEARCH ARE: TREATMENT ALGORITHMS Implement sedation to provide consistent care based on clear principals. Purpose Background Methods Results Discussion Conclusion References EDUCATION MODULE: An education module provided by the pediatric pain service with CE’s was given to the RN’s in June of 2010. SEDATION GOALS: Implementation of sedation goals with education to nursing and physicians at rounds to establish a common language to describe the patient’s pain and sedation needs March 2010. PAIN & SEDATION TREATMENT ALGORITHMS: Once this has been accomplished pharmacy and physicians incorporated pain and sedation algorithms to provide more consistent approach to the management and allow nursing to have more autonomy to provide care in Feb 2011. (see example below) Survey: Likert type survey developed by the Pediatric Pain Service and adapted for use in the PCTU. While pain was consistently assessed in the PCTU as evidenced by our 100% compliance with this nursing quality indicator for 2010, it was evident that patients were receiving different treatments based on caregiver characteristics instead of patient assessment data in some cases. Work was being done in silos by physicians, pharmacy and nursing. Formation of a multidisciplinary group, along with support from the pediatric pain service, worked to break down the silos and barriers to care providers using the same language to describe pain and sedation in the PCTU. The creation of order sets for sedation goals was implemented in October 2010 and order sets for the medication algorithms were implemented in February 2011. PRE-IMPLIMENTATIN SURVEY: Nurses, physicians, and nurse practitioners were surveyed prior to implementation of the project to evaluate their level of comfort and feelings of success in treating pain, managing sedation, agitation and withdrawal in the PCTU patient population in March 2010 POST-IMPLIMENTATION SURVEY: Surveys were given to RN’s & NP’s who were on the unit prior to the roll out of the program. The roll out occurred over 18 months. Text Of the nurses surveyed, 80% have been ICU nurses greater than 6 years. This demonstrates that experienced nurses perceived benefits to their skills related to pain, agitation, sedation, and withdrawal. The assessment and treatment of agitation and withdrawal continue to be areas the PCTU nurses want to be more proficient at. Deeter K. & King M et al. Successful implementation of a pediatric sedation protocol for mechanically ventilated patients. Critical Care Medicine 2011; 39 (4): 683-688. Franck L, & Harris S, et al. The Withdrawal Assessment Tool–1 (WAT–1): An assessment instrument for monitoring opioid and benzodiazepine withdrawal symptoms in pediatric patients. Pediatric Critical Care Medicine 2008; 9 (6): 573-580. Malviya, S. Voepel-Lewis, T. Burke, C. Merkel, S. & Tait, A. (2006). The revised FLACC observational pain tool: improved reliability and validity for pain assessment in children with cognitive impairment. Pediatric Anesthesia, 16, 258-265. Malviya S, Voepel-Lewis T, Merkel S et al. Difficult pain assessment and lack of clinician knowledge are ongoing barriers to effective pain management in children with cognitive impairment. Acute Pain 2005; 7: 27–32. Voepel-Lewis T, Merkel S, Tait AR et al. The reliability and validity of the face, legs, activity, cry, consolability observational tool as a measure of pain in children with cognitive impairment. Anesth Analg 2002; 95: 1224–1229. PCTU Sedation Algorithm: Early Extubation Group Fast Track Extubation: Extubate within 6 hours from the end of surgery Morphine 20 mcg/kg/hr +/- Propofol 40-80 mcg/kg/min Morphine prn pain per Pain Score Midazolam prn procedural and short- term sedation Discontinue Propofol 30- 60 minutes prior to extubation ***Inadequate pain control after extubation  Ketoralac 0.25-0.5 mg/kg/dose IV Q6H x 48 hrs and re-evaluate (max 5 days/hospitalization Sedation & Pain Management Issues Pre- Implementation Post- Implementation Knowledge: analgesic, agitation, & sedation treatment options 70%88% ******** Management: Discussion at rounds Team communication Consistent standards 67% 47% 60% 100% ******* 89% ******* 74% Assessment: Difficult to distinguish pain behaviors from others Difficult to distinguish pain from agitation 50% 70% 34% 92% Issues Cont.PrePost Difficulty providing sedation to critically ill children Inadequate education, practice guidelines, lack of communication & documentation (>50%) Nurses didn’t report these concerns as high on the post- survey. Evaluation of care in the PCTU Too little use of sucrose, non-opioids, noise control Too little use of noise control, massage/touch, non-opioids Prioritization of education that needs to occur Asses Agitation Asses Pain Sedation Guidelines/protocols Assess Agitation