1. Pain, Agitation, and Delirium: Bringing it All Together Peter Dodek

2. Aim Measures Change concepts and specific changes

3. 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

4. Become Familiar with This Document: Critical Care Medicine. 2013; 41: 263-306.

5. Aim: Begin with the End in Mind… Critical Care Medicine. 2013; 41: 263-306. -to reduce pain, agitation, and delirium in all ICU patients

6. 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

7. 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.

8. 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.

9. 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

10. Example of Language in a Checklist: SPH ICU rounds checklist April 2, 2013

11. 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 ICU 2.Multi-disciplinary 3.Evidence-based

12. Music Therapy Decreases Pain and Agitation Jaber S et al. Annales Francaises d’Anesthesie et de Reanimation. 2007

13. Music Therapy Decreases Sedation Frequency in Mechanically Ventilated Patients Chlan LL et al. JAMA 2013 Patient-directed music Noise-cancelling headphones Usual care

14. Randomized Controlled Trial of PAD protocol (patient-level, per-protocol analysis) Mansour P et al. JCC 2013

15. Randomized Controlled Trial of PAD protocol (patient-level, per-protocol analysis) Mansour P et al. JCC 2013

16. Implementing Guidelines for Detection and Treatment of Delirium in a 21- hospital System Adams CL et al. Clin Nurse Specialist. 2015

17. Implementing Guidelines for Detection and Treatment of Delirium in a 21- hospital System Adams CL et al. Clin Nurse Specialist. 2015

18. Amaral ACKB et al. Crit Care 2012 Analysis: Interrupted Time-series vs. Before- after (intervention: minimizing sedation)

19. Uses of RASS: Comparison of Appropriate Responses to RASS Dodek P et al. BMJ Qual Safety. 2012

20. PAD Management and Maslow’s Hierarchy of Needs in Critical Care Jackson JC et al. JCC 2014

21. 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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