1. More Bang for Your Bundle:
Implementing Routine Pain, Agitation, and Delirium (PAD) Care in the ICU
Neil Roe, PharmD, BCCCP
Clinical Pharmacy Specialist – Critical Care
Baptist Health Medical Center
Little Rock, AR
AAHP Fall Seminar 2017

2. I have no conflicts of interest to disclose.

3. Pharmacist Objectives
Define pain, agitation, and delirium (PAD) in the intensive care unit (ICU)
Identify best practices for management of PAD
Discuss the benefits of a care bundle in the ICU
Design a process for implementation of a PAD care bundle

4. Technician Objectives
Describe pain, agitation, and delirium (PAD) in the intensive care unit (ICU)
Discuss the best practices for management of PAD
Examine the benefits of a care bundle in the ICU
Form a plan for implementation of a PAD care bundle

5. Complexity of PAD
Reade mc, finfer s. N Engl J Med. 2014;370(5):444-54

6. Pain Complications Disease Invasive Devices Immobility Routine Care
“An unpleasant sensory and emotional experience associated with actual or potential tissue damage.”
Disease
Invasive Devices
Immobility
Routine Care
Complications
Chronic pain
Stress
Sleep-loss
Hyper-metabolism
Impaired wound healing
Impaired immune function
Feelings of Helplessness
Post-traumatic stress disorder
Barr, et al. Crit Care Med. 2013;41(1):

7. Behavioral Pain Scale (BPS) Critical Care Pain Observation Tool (CPOT)
Assessment of Pain
Question: Can pain be accurately assessed in the ICU?
Obstacles:
Subjective, differs between individuals
Self-reporting = GOLD standard
Behavioral Pain Scale (BPS)
Critical Care Pain Observation Tool (CPOT)
Sigakis, et al. Crit Care Med. 2015;43(11):

8. Options for Pain Non-neuropathic pain Neuropathic pain Acute pain
IV Opioids
Acute pain
Gabapentin
Carbamazepine
Neuropathic pain
NSAIDS
Acetaminophen
Ketamine
Non-neuropathic pain
Barr, et al. Crit Care Med. 2013;41(1):

9. Pain - Summary
Guideline Statement: “We suggest that pain be routinely monitored in all adult ICU patients.”
Guideline Statement: “We recommend that IV opioids be considered as the first-line drug class of choice to treat non-neuropathic pain…”
Guideline Statement: “Analgesia-first sedation should be used in mechanically ventilated adult ICU patients…”
Barr, et al. Crit Care Med. 2013;41(1):

10. Patient Population Intervention Outcomes Studied
Patients needing mechanical ventilation for >24 hours
Intervention
Analgesia “Only” vs. Sedation
Morphine IV push, verbal reassuring
Haloperidol given for delirium
Propofol x6 hours if still uncomfortable
Outcomes Studied
Primary: Days without mechanical ventilation (first 28 days)
Secondary: Length of stay, accidental extubations, pneumonia
Strøm, et al. Lancet. 2010;375(9713):

11. Strøm, et al. Lancet. 2010;375(9713):475-80.

12. Days off ventilator – 4.2 days
ICU stay – 9.7 days
Strøm, et al. Lancet. 2010;375(9713):

13. Review Question #1
1. Among those listed, which medication is the preferred option for acute pain in the ICU?
Ketamine
Acetaminophen
Morphine
Ketorolac

14. Photo: “Lumex Nightmare” by Ralph Sirianni
Agitation
“A syndrome of excessive motor activity, usually non-purposeful and associated with internal tension.”
Sources
Pain
Hypoxia
Withdrawal
Hypoglycemia
Delirium
Hypotension
Photo: “Lumex Nightmare” by Ralph Sirianni
Reade, Crit Care. 1999;3(3):R35-R46.
Barr, et al. Crit Care Med. 2013;41(1):

15. Assessment of Agitation
accessed May 19, 2017
Riker, et al. Crit Care Med 1999;27:

16. Options for Sedation Barr, et al. Crit Care Med. 2013;41(1):263-306.
Benzodiazepines
Propofol
Dexmedetomidine
Barr, et al. Crit Care Med. 2013;41(1):

17. Respiratory Depression
Options for Sedation
Midazolam
Propofol
Dexmedetomidine
Amnesia X
Analgesia
Anticonvulsion
Antiemesis
Anxiolysis
Hypnosis
Sedation
Bradycardia
Hypotension
Respiratory Depression
Barr, et al. Crit Care Med. 2013;41(1):

18. Shehabi, et al. Am J Respir Crit Care Med. 2012;186(8):724-31.

19. Patient Population Comparison Outcomes Studied
On mechanical ventilation
Receiving continuous or intermittent sedation and/or analgesia
Comparison
Deeply sedated vs. Not deeply sedated
Deeply sedated = RASS -5 to –3 within the first 48 hours
Outcomes Studied
The impact of sedation practices on:
Time to extubation
Delirium
Mortality (180-day)
Shehabi, et al. Am J Respir Crit Care Med. 2012;186(8):

20. Median time to extubation:
7.7 days vs. 2.4 days
Shehabi, et al. Am J Respir Crit Care Med. 2012;186(8):

21. 180-day Mortality
Shehabi, et al. Am J Respir Crit Care Med. 2012;186(8):

22. Fraser, et al. Crit Care Med. 2013;41(9 Suppl 1):S30-8.

23. ICU Length of Stay
Fraser, et al. Crit Care Med. 2013;41(9 Suppl 1):S30-8.

24. Duration of Mechanical Ventilation
ICU Length of Stay
Fraser, et al. Crit Care Med. 2013;41(9 Suppl 1):S30-8.

25. Agitation - Summary
Guideline Statement: “Maintaining light levels of sedation in adult ICU patients is associated with improved clinical outcomes.”
Guideline Statement: “We recommend either daily sedation interruption or a light target level of sedation be routinely used in mechanically ventilated adult ICU patients.”
Guideline Statement: “The use of sedation scales, sedation protocols designed to minimize sedative use, and the use of nonbenzodiazepine medications are associated with improved ICU patient outcomes.”
Barr, et al. Crit Care Med. 2013;41(1):

26. Review Question #2
2. Deep sedation in the ICU is associated with which of the following outcomes?
Increased ICU length of stay
Increased mortality
Both A and B
None of the above

27. Delirium & Inattention & & Disorganized Thinking
“Sudden, severe confusion and rapid changes in brain function that occur with physical or mental illness.”
Acute Change or Fluctuation in Mental Status
&
Inattention
&
&
Disorganized Thinking
Altered Level of Consciousness OR
Delirium
Barr, et al. Crit Care Med. 2013;41(1):

28. Delirium Complications Increased LOS Increased cost
Increased time on ventilator
Agitation
Long term cognitive deficits
Mortality
Barr, et al. Crit Care Med. 2013;41(1):
Reade mc, finfer s. N Engl J Med. 2014;370(5):
Marra, et al. Crit Care Clin. 2017;33(2):
Salluh, et al. BMJ. 2015;350:h2538.

29. Analysis of 28 studies p<0.001 Analysis of 28 studies p<0.001
Salluh, et al. BMJ. 2015;350:h2538.

30. Delirium Day Up to 80% 2 to 3 11 Assessed via:
Confusion Assessment Method (CAM-ICU)
Intensive Care Delirium Screening Checklist (ICDSC)
Incidence of delirium during stay
Average time of onset
Number of risk factors present
Up to 80%
Day
2 to 3 11
Numbers worth noting
Marra, et al. Crit Care Clin. 2017;33(2):
Barr, et al. Crit Care Med. 2013;41(1):

31. “…Lorazepam was an independent risk factor for daily transition to delirium…”
Pandharipande, et al. Anesthesiology. 2006;104(1):21-6.

32. Delirium – Risk Factors
At Baseline
(Non-Modifiable)
During Stay
(Modifiable)
Dementia
Coma
Hypertension
Benzodiazepines
Alcoholism
Narcotics
Higher severity of illness
Immobility
Age
Sleep deprivation
Jackson p, khan, a. Crit Care Clin. 2015;31(3):
Barr, et al. Crit Care Med. 2013;41(1):

33. Delirium Treatment
Guideline Statement: “There is no published evidence that treatment with haloperidol reduces the duration of delirium.”
Guideline Statement: “Atypical antipsychotics may reduce the duration of delirium.” (Level C)
Barr, et al. Crit Care Med. 2013;41(1):

34. Delirium Prevention
Guideline Statement: “We provide no recommendation for a pharmacologic delirium prevention protocol…”
Guideline Statement: “Benzodiazepine use may be a risk factor for the development of delirium…”
Guideline Statement: “We recommend performing early mobilization…to reduce the incidence and duration of delirium”
Barr, et al. Crit Care Med. 2013;41(1):

35. Review Question #3
3. The 2013 PAD guidelines recommend which of the following agents for prevention of delirium?
Haloperidol
Lorazepam
Ziprasidone
None of the above

36. PAD Management PAD management presents many challenges
A few specific strategies have demonstrated success
Implementation and performance is inconsistent
Barr, et al. Crit Care Med. 2013;41(1):

37. Complexity of PAD
Reade mc, finfer s. N Engl J Med. 2014;370(5):444-54

38. Could an ICU care bundle be the answer?
Complexity of PAD
Simplicity
Could an ICU care bundle be the answer?
Reade mc, finfer s. N Engl J Med. 2014;370(5):444-54

39. ICU Care Bundle
A care bundle usually consists of 3-5 interventions that when performed together:
Produce better outcomes than when done individually
Help ensure delivery of standards of care
Allow for easier auditing to assess delivery of care
Sepsis
Ventilator Associated Pneumonia
Catheter Associated Infections
Continuing Education in Anaesthesia Critical Care & Pain, Volume 12, Issue 4, 1 August 2012, Pages 199–202

40. PAD Management
Guideline Statement: “A successful strategy is to implement an evidence-based, institutionally-specific, integrated PAD protocol, and to assess, treat and prevent PAD, using an interdisciplinary team approach.”
Guideline Statement: “For acutely hospitalized patients ventilated for more than 24 hours, we suggest protocols attempting to minimize sedation.”
-2013 Guidelines for Management of PAD in Adult ICU Patients
-2016 Guidelines for Liberation from Mechanical Ventilation
Barr, et al. Crit Care Med. 2013;41(1):
Ouellette, et al. Chest. 2017;151(1):

41. A B C D E F ABCDEF Care Bundle Assess, prevent, & manage pain
Both SAT and SBT C
Choice of analgesia and sedation D
Delirium: Assess, prevent, manage E
Early mobility and exercise F
Family engagement and empowerment
Iculiberation.org

42. Dale Cr, et al. Ann Am Thorac Soc. 2014;11:367-374

43. Design Patient Population Intervention Outcomes Studied
Single center
Before & after
Patient Population
Surgical/Trauma ICU
On mechanical ventilation
Intervention
Hospital update of PAD protocol
Emphasized:
Increased assessment by nursing
Reducing amount of sedation
Pairing awakening and breathing trials
Outcomes Studied
Primary: Time on mechanical ventilation
Secondary: Delirium, ICU & hospital LOS
Dale Cr, et al. Ann Am Thorac Soc. 2014;11:

44. Design Patient Population Intervention Outcomes Studied
Single center
Before & after
Patient Population
Surgical/Trauma ICU
On mechanical ventilation
Intervention
Hospital update of PAD protocol
Emphasized:
Increased assessment by nursing
Reducing amount of sedation
Pairing awakening and breathing trials
Outcomes Studied
Primary: Time on mechanical ventilation
Secondary: Delirium, ICU & hospital LOS
*17.6% - reduction in time on mechanical ventilation
*12.4% - reduction in ICU LOS
*14% - reduction in hospital LOS
*Represent statistically significant results
Dale Cr, et al. Ann Am Thorac Soc. 2014;11:

45. Barnes-Daly, et al. Crit Care Med. 2017;45(2):171-178.

46. Barnes-Daly, et al. Crit Care Med. 2017;45(2):171-178.

47. Barnes-Daly, et al. Crit Care Med. 2017;45(2):171-178.

48. From Idea to Initiative
Find Opportunity
Find Stakeholders
Find Champions
Commit to the Cause
Getting off the ground…

49. Prepare to Present Healthcare equivalent of a “business plan”
Define success & how you will measure it
Master this presentation!
Introduce/pitch this to multiple parties
Nursing administration
Hospital administration
P&T committees, other physician groups as needed
Secure approval and get to work

50. Rules from Start to Finish
Make friends
Know the roles of your stakeholders
Don’t decide what hasn’t been discussed
Be invested in YOUR plan, but be open to ideas
Appreciate each step forward

51. Broadly Speaking… Create an “opt-out” protocol
Set Expectations
Convert them to Orders
Educate
Encourage & Enforce
Create an “opt-out” protocol
How will you put this protocol in motion?
Order sets
Written plan

52. One Step at a Time: A Is your pain scale appropriate?
Create expectation for frequency / documentation
Tip: EHR should prompt a response
Evaluate current analgesic strategies
If good, formalize them
Collaborate to develop a “treatment pathway”
Do not let sedation mask pain
EHR = Electronic Health Record

53. One Step at a Time: B Awakening Breathing
Define and detail performance
Set a convenient time
The default is “yes”
Daily handoff to respiratory
Breathing
Expect daily handoff
The default is “yes”
Perform according to ATS / CHEST
Chart the result
ATS – American Thoracic Society

54. One Step at a Time: C
Active Meds
Drugs of Abuse
Home Meds
Are analgesics / sedatives in line with the bundle
Were the previous 24 hours successful?
Do they fit today’s care plan? Today’s organ function?
Expectation for physician communication

55. One Step at a Time: D Prevent what is difficult to treat
Screen
Treat
Prevent what is difficult to treat
Screen once per shift using CAM-ICU or ICDSC
Treat by removing, then treat by adding

56. One Step at a Time: E Enlist your physical / occupational therapists
Assess the current approach to ventilated patients
Determine feasibility of a new approach
Create the expectation for movement
accessed August 2017

57. One Step at a Time: F
Family participation should be standard in the ICU
Work to enact policies that allow:
Family presence
Family involvement in both decisions and management
Benefits include:
Staff accountability
Physical / emotional comfort for the patient
Reduction in post traumatic stress disorder
Jones, et al. Crit Care. 2010;14:R168.

58. Negotiate Warranty Period
From Plan to Protocol
“Go-live” Date
Negotiate Warranty Period
Avenue for Feedback
Go-live!
Evaluate Progress

59. Final Thoughts 2013 2016 Present Future
SCCM
ATS/CHEST
Your ICU
Your Site
Guidelines for PAD
Guidelines Ventilator Liberation
Obligation to Implement Best Practices
Improved Patient Outcomes
“Knowing the benefits of these strategies and choosing not to perform them is no different than withholding a course-altering, potentially life-saving medication therapy.”

60. More Bang for Your Bundle:
Implementing Routine Pain, Agitation, and Delirium (PAD) Care in the ICU
Neil Roe, PharmD, BCCCP
Clinical Pharmacy Specialist – Critical Care
Baptist Health Medical Center
Little Rock, AR
AAHP Fall Seminar 2017