1. Today’s Webinar will begin at 10:30AM
7/26/12

2. Introduction
Hi, my name is Kate, and I will be facilitating the discussion for today’s webinar…

3. More Introduction
Please do not put your phone on hold; use the mute function or *6
Please type questions or comments into “Chat” or “Q&A” text boxes to the right of your screen
If time permits, we will open up the phone lines at the conclusion of the presentation

4. Juliana Barr, MD, FCCM Acting Medical Director, Critical Care VA Palo Alto Health Care System
It is my pleasure to introduce Connie……

5. Delving Into the ICU Pain, Agitation, & Delirium Care Bundle
ACCM’s 2012 ICU PAD Guidelines
Juliana Barr, MD, FCCM
Chair, ACCM PAD Guideline Task Force
Associate Professor of Anesthesia,
Stanford University School of Medicine
Associate ICU Medical Director,
VA Palo Alto Health Care System

6. No Commercial Affiliations....
COI Disclosures
No Commercial Affiliations....

7. Learning Objectives
What’s new in the ACCM ‘s 2012 Pain, Agitation, and Delirium Clinical Practice Guidelines for Adult ICU Patients.
Use of validated scales for assessing pain, sedation, and delirium in the management of critically ill patients.
Integrating the management of pain, agitation, and delirium in adult ICU patients.
Applying these principles in your ICU. 7

8. 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, MSc
Critical Care Medicine (In press)

9. What’s Different about this Version of the PAD Guidelines?-Methods
Professional librarian:
Charlie Kishman, MSLS, Univ. of Cincinnati
Developed MeSH terms, conducted standardized searches, managed Refworks ™ database.
Electronic Database:
Web-based database (Refworks™ software)- >19,000 refs!
Accessible on-line to all Task Force members.

10. What’s Different about this Version of the PAD Guidelines
What’s Different about this Version of the PAD Guidelines?-Methods (cont.)
GRADE Methodology: (
More rigorous , transparent process – minimizes COI.
Strength of recommendations = strength of evidence + relative risks, benefits of interventions – more practical, applicable.
Expert opinion not used as a substitute for making recommendations without evidence – more robust.
Voting Process:
Anonymous on-line voting (E-survey™) by all Task Force members.
Polling managed by SCCM staff.
Standardized voting thresholds used to achieve consensus for all statements and recommendations.

11. What’s Different about this Version of the PAD Guidelines? − Content
Psychometric assessments comparing pain, sedation, delirium monitoring tools (defines the most valid, reliable, and feasible tools to use in ICU patients).
More patient-centered, integrated, and interdisciplinary approach to managing pain, agitation, and delirium (less emphasis on drug recipes).
Greater emphasis on the pathophysiology, risks, and management of delirium.

12. What’s Different About this Version of the PAD Guidelines? − Scope
Way bigger than the last version!
Total of 53 statements and recommendations!
vs. 28 recommendations in the 2002 SAG Guidelines.
vs. 36 statements, recommendations in the 2008 Sepsis Guidelines.
Not meant to be comprehensive:
Attempts to answer the most important questions related to pain, agitation, and delirium in ICU patients.
Some questions have no answers due to a lack of evidence.
Identifies area for future research.

13. 2012 Pain, Agitation, and Delirium Clinical Practice Guidelines
Why are they significant?

14. Early Mobility of ICU Patients

15. Integrated PAD Management
Delirium Prevention, Treatment
Agitation
Sedation/
Pain Management

16. The Path to PAD Integration… ABCDE Bundle*
*Awakening and Breathing Coordination, Delirium Management, and Early Mobility and Exercise

17. PAD Interdisciplinary Team
Integrated Approach to PAD
MD Champion
RN Champion
RT Champion
Pharmacy Champion
Physical Therapy Champion
Hospital Administrators
Family
Patient

18. PAD Guideline Implementation
MD Champion!
PAD Implementation (%)
Interdisciplinary PAD
Stakeholder Team

19. Expected Benefits of Implementing the PAD Guidelines
Shortened duration of MV
Reduced ICU, hospital LOS
Increased ICU patient throughput, bed availability
Decreased costs per patient
Improved long-term cognitive function, mobility
Increased number of patients discharged to home!
Lives saved!

20. ICU PAD Care Bundle PAIN AGITATION DELIRIUM ASSESS TREAT PREVENT
Assess pain ≥ 4x/shift & prn
Preferred 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 ≥ 3
Assess agitation, sedation ≥ 4x/shift & prn
Preferred sedation assessment tools:
RASS (-5 to +4) or SAS (1 to 7)
NMB  suggest using brain function monitoring
Depth of agitation, sedation defined as:
agitated if RASS = +1 to +4, or SAS = 5 to 7
awake and calm if RASS = 0, or SAS = 4
lightly sedated if RASS = -1 to -2, or SAS = 3
deeply sedated if RASS = -3 to -5, or SAS = 1 to 2
Assess delirium Q shift & prn
Preferred delirium assessment tools:
CAM-ICU (+ or -)
ICDSC (0 to 8)
Delirium present if:
CAM-ICU is positive
ICDSC ≥ 4
ASSESS
Treat pain within 30” then reassess:
Non-pharmacologic treatment– relaxation therapy
Pharmacologic treatment:
Non-neuropathic pain IV opioids +/- non-opioid analgesics
Neuropathic pain gabapentin or carbamazepine, + IV opioids
S/p AAA repair, rib fractures  thoracic epidural
Targeted sedation or DSI (Goal: patient purposely follows commands without agitation): RASS = -2 – 0, SAS = 3 - 4
If 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 dose
Treat pain as needed
Reorient patients; familiarize surroundings; use patient’s eyeglasses, hearing aids if needed
Pharmacologic treatment of delirium:
Avoid benzodiazepines unless ETOH or benzodiazepine withdrawal suspected
Avoid rivastigmine
Avoid antipsychotics if  risk of Torsades de pointes
TREAT
Legend:
IPAD Care Bundle = ICU Pain, Agitation, and Delirium Care Bundle
NRS = Numeric Rating Scale
BPS = Behavioral Pain Scale
CPOT = Critical-Care Pain Observation Tool
Non-pharmacologic therapy = relaxation therapy, especially for chest tube removal
IV = intravenous
AAA = abdominal aortic aneurysm
NMB = neuromuscular blockade
RASS = Richmond Agitation and Sedation Scale
SAS = Sedation Agitation Scale
Brain 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 = ethanol
Non-benzodiazepines = propofol (use in intubated/mechanically ventilated patients), dexmedetomidine (use in either intubated or non-intubated patients).
SBT = spontaneous breathing trial
EEG = electroencephalography
ICP = intracranial pressure
CAM-ICU = Confusion Assessment Method for the ICU
ICDSC = ICU Delirium Screening Checklist
Administer pre-procedural analgesia and/or non-pharmacologic interventions (eg, relaxation therapy)
Treat pain first, then sedate
Consider daily SBT, early mobility and exercise when patients are at goal sedation level, unless contraindicated
EEG monitoring if:
at risk for seizures
burst suppression therapy is indicated for ICP
Identify delirium risk factors: dementia, HTN, ETOH abuse, high severity of illness, coma, benzodiazepine administration
Avoid benzodiazepine use in those at  risk for delirium
Mobilize and exercise patients early
Promote sleep (control light, noise; cluster patient care activities; decrease nocturnal stimuli)
Restart baseline psychiatric meds, if indicated
PREVENT

21. Implementing the ICU PAD Care Bundle
PAIN
AGITATION
DELIRIUM
Assess pain ≥ 4x/shift & prn
Preferred 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 ≥ 3
Assess agitation, sedation ≥ 4x/shift & prn
Preferred sedation assessment tools:
RASS (-5 to +4) or SAS (1 to 7)
NMB  suggest using brain function monitoring
Depth of agitation, sedation defined as:
agitated if RASS = +1 to +4, or SAS = 5 to 7
awake and calm if RASS = 0, or SAS = 4
lightly sedated if RASS = -1 to -2, or SAS = 3
deeply sedated if RASS = -3 to -5, or SAS = 1 to 2
Assess delirium Q shift & prn
Preferred delirium assessment tools:
CAM-ICU (+ or -)
ICDSC (0 to 8)
Delirium present if:
CAM-ICU is positive
ICDSC ≥ 4
ASSESS
Treat pain within 30” then reassess:
Non-pharmacologic treatment– relaxation therapy
Pharmacologic treatment:
Non-neuropathic pain IV opioids +/- non-opioid analgesics
Neuropathic pain gabapentin or carbamazepine, + IV opioids
S/p AAA repair, rib fractures  thoracic epidural
Targeted sedation or DSI (Goal: patient purposely follows commands without agitation): RASS = -2 – 0, SAS = 3 - 4
If 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 dose
Treat pain as needed
Reorient patients; familiarize surroundings; use patient’s eyeglasses, hearing aids if needed
Pharmacologic treatment of delirium:
Avoid benzodiazepines unless ETOH or benzodiazepine withdrawal suspected
Avoid rivastigmine
Avoid antipsychotics if  risk of Torsades de pointes
TREAT
Legend:
IPAD Care Bundle = ICU Pain, Agitation, and Delirium Care Bundle
NRS = Numeric Rating Scale
BPS = Behavioral Pain Scale
CPOT = Critical-Care Pain Observation Tool
Non-pharmacologic therapy = relaxation therapy, especially for chest tube removal
IV = intravenous
AAA = abdominal aortic aneurysm
NMB = neuromuscular blockade
RASS = Richmond Agitation and Sedation Scale
SAS = Sedation Agitation Scale
Brain 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 = ethanol
Non-benzodiazepines = propofol (use in intubated/mechanically ventilated patients), dexmedetomidine (use in either intubated or non-intubated patients).
SBT = spontaneous breathing trial
EEG = electroencephalography
ICP = intracranial pressure
CAM-ICU = Confusion Assessment Method for the ICU
ICDSC = ICU Delirium Screening Checklist
Administer pre-procedural analgesia and/or non-pharmacologic interventions (eg, relaxation therapy)
Treat pain first, then sedate
Consider daily SBT, early mobility and exercise when patients are at goal sedation level, unless contraindicated
EEG monitoring if:
at risk for seizures
burst suppression therapy is indicated for ICP
Identify delirium risk factors: dementia, HTN, ETOH abuse, high severity of illness, coma, benzodiazepine administration
Avoid benzodiazepine use in those at  risk for delirium
Mobilize and exercise patients early
Promote sleep (control light, noise; cluster patient care activities; decrease nocturnal stimuli)
Restart baseline psychiatric meds, if indicated
PREVENT

22. Time for a Quick Poll!
Please answer the following poll questions as they relate to your facility.

23. ICU PAD Care Bundle − Metrics
PAIN
AGITATION
DELIRIUM
% of time patients are monitored for pain ≥ 4x/shift
Demonstrate local compliance and implementation integrity over time in the use of ICU pain scoring systems
% of time sedation assessments are performed ≥ 4x/shift
Demonstrate local compliance and implementation integrity over time in the use of ICU sedation scoring systems
% of time delirium assessments are performed Q shift
Demonstrate local compliance and implementation integrity over time in the use of ICU delirium assessment tools
ASSESS
% of time ICU patients are in significant pain (ie, NRS ≥ 4, BPS ≥ 6, or CPOT ≥ 2)
% 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)
TREAT
Legend:
NRS = Numeric Rating Scale
BPS = Behavioral Pain Scale
CPOT = Critical-Care Pain Observation Tool
RASS = Richmond Agitation and Sedation Scale
SAS = Sedation Agitation Scale
ETOH = ethanol
DSI = daily sedation interruption
SBT = spontaneous breathing trial
EEG = electroencephalography
ICP = intracranial pressure
CAM-ICU = Confusion Assessment Method for the ICU
ICDSC = ICU Delirium Screening Checklist
NOTE: 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 LOS
3) Mortality: ICU, hospital
4) 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 seizures
burst 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 protocols
PREVENT

24. ICU PAD Bundle Toolkit Instructional videos
Bedside pain, sedation/agitation, and delirium assessments
Early mobility techniques
PowerPoint presentations−staff education
Pocket cards−bundle, guideline recommendations
Templates−checklists, goal sheets, protocols, etc

25. The ICU PAD Care Bundle

26. Facilitated discussion/questions; we will now open up the lines for discussion/questions

27. Notes will be on our website… www.cynosurehealth.org
Slides and audio from today’s presentation will be posted on our website

28. Check out our website for future events

29. Join us for a FREE Webinar
ICU Pain, Agitation & Delirium Care Bundle Metrics: Measurement for Improvement
Join us for a FREE Webinar
Thursday, August 30, 2012
11:00 AM - 12:00 PM
The soon-to-be published Pain, Agitation and Delirium (PAD) Guidelines from the American College of Critical Care Medicine (ACCM) outline, in great detail, recommendations for the assessment, treatment and prevention of pain, agitation and delirium in ICU patients. But how do you assess your hospital's performance in these areas?
Please join us for a free webinar where Juliana Barr, MD, FCCM and Chair of ACCM's Task Force to revise these clinical practice guidelines, will discuss the metrics used to assess performance with ICU PAD Care Bundle.
This will be an interactive program with the opportunity to submit/ask questions.

30. Thanks for joining us today!
We appreciate your time, thanks for joining us, and we look forward to seeing you at a future Cynosure Health Event.