Pain, Sedation and Delirium
Collaborative
Critical Care Unit
May 28-29th, 2012
Background
•Large community teaching hospital servicing
400 in-patient beds within the Central LHIN
•Annual inpatient volumes of 27,738
•24 bed level 3 Intensivist led Critical Care Unit
providing medical/surgical and cardiac care
•Dedicated to initiating and sustaining quality improvement
initiatives
Aim – Purpose and Scope
• The purpose of this initiative is to implement a
standardized approach to the assessment and
management of pain, sedation and delirium for ALL
patients admitted to our Critical Care Unit (CrCU)
• We aim for this project to be part of an “ABCDE”
bundle approach to the care of our critically ill
patients
Our ABCDE Approach
• Evidenced based “ABCDE” bundle representing an integrated and interprofessional approach to the management of mechanically ventilated patients
• Awakening and Breathing Coordination
• VAMAAS Score
• Daily Spontaneous Breathing Screens and Trials
• Delirium
•
•
•
•
Education
Intensive Care Delirium Screening Checklist
Integration into Daily Goal Sheets
Introduction of Dextmedetomidine (Precedex) to
formulary
• Early Exercise and Mobility
• “Lifty Pants” Mobility devices for walking
Aim - Objectives
• Identify a standardized screening tool for the assessment of
pain, sedation and delirium by February 2012
• Implement standardized pain, sedation and delirium
screening tools on 100% of all CrCU patients by May 2012 and
then September 2012 for on-line documentation
• Determine current use of anti-psychotics, sedatives and
analgesics in CrCU patients
• Create an education package on delirium definition,
assessment and tools by March 2012
Team Members
Core Team Members:
• Katrina Ayotte, RN
• Darlene Baldaro, RRT
• Roxane Bobb-Semple, RN
• Bonnie Chi Thieu, Pharmacy
• Jo-Ann Correa, RN, Project Coordinator
• Jennifer Laurin, RN
• Karen Johnson, RN, Clinical Team Manager
• Phil Shin, MD, Intensivist
• Catharine Steenhoek, RN
• Kathy Tossios, PT
Ad Hoc Team Members:
• Meghan Ralston, RN, Application Specialist
• Millie Paupst, MD, Psychiatry
• Steve Latchan, Team Attendant
• Donna McRitchie, MD, Intensivist
Changes Tested
• Empowerment of front-line staff to identify and manage
delirium
• Standardize clinical processes to manage delirium (e.g. bundle
strategies added to CrCU daily goal sheet)
• Use of validated screening tool to assess and manage sedation
(VAMAAS)
• Use of validated screening tool to assess and manage delirium
(ICDSC)
• Integrate pain, sedation and delirium assessment and
management into daily rounds
Changes Tested
PDSA Cycle #6 Educate a group of staff
Using Pain, Sedation and Delirium Presentation
GO LIVE – May 3rd, 2012
PDSA Cycle #5 – Identify all the ventilated patients
Who did not have an SBT due to sedation
PDSA Cycle #4 – Two independent Team members
Complete the ISDSC checklist on the same patient
PDSA Cycle #2-3 – Complete the Intensive Care Delirium
Screening Checklist on 1 patient
PDSA Cycle #1 – Audit of documented VAMAAS and Pain Scores
On Ventilated patients during daily goal rounds during 1 shift
Results
• Pain, Sedation and Delirium Pre-Survey Completed
• Intensive Care Delirium Screening Checklist identified as
validated tool and adapted by team using small tests of
change
• Daily Goal Sheet revised to reflect the validated pain, sedation
and delirium screening tools and serve as prompt during daily
goal rounds
• 85% of staff educated by Go-Live date
• Data collected for 10 days following go live
Pre-Survey Results
Pain, Sedation and Delirium
Comfort Level when Assessing Patients for Pain, Sedation and Delirium
Percentage of Respondants (%)
100
90
80
70
60
50
40
30
20
10
0
Not Comfortable
Comfortable
Pain
Sedation
Extremely Comfortable
Delirium
Pre-Survey Results –
Knowledge regarding Delirium
Percentage of Respondants (n=23)
Delirium - Knowledge Level
100
90
80
70
60
50
40
30
20
10
0
Signs and Symptoms of Delirium
Identification of Appropriate Strategies
to prevent Delirium
Extremely Knowldgeable
Knowledgeable
Identification of Appropriate
Interventions for paients with delirium
Not knowledgeable at all
Results: Staff Education
• Education kick off April 10th with 4 in-services for day and
night staff
• Education provided by Pain, Sedation
and Collaborative Team members
• Support provided by education team
members
• Education also emailed to all staff
members for review
Results
Revised ICDSC Tool
• Original ICDSC tool used
for PDSA cycles 2-3
• Revisions made to tool
reflect feedback from
PDSA cycles
• Currently used in paper
chart but will be available
on-line as of June 26th,
2012
Revised Daily Goal Sheet
• Changes reflect many elements
of the new checklist as
reminders to help us improve
on preventing delirium from
happening (e.g. keeping track
of sleep-wake cycles)
Early Data –
Prevalence of Opiod, Benzodiazepine and Antipsychotic use in the CrCU
• 60% of patients who received PRN fentanyl/morphine also received PRN
benzodiazepine during the same day
• 21% of patients who received an antipsychotic (ATC or PRN) also received PRN
benzodiazepine during the dame day
5/
2/
20
12
5/
3/
20
12
5/
4/
20
12
5/
5/
20
12
5/
6/
20
12
5/
7/
20
12
5/
8/
20
12
5/
9/
20
12
5/
10
/2
01
2
5/
11
/2
01
2
5/
12
/2
01
2
5/
13
/2
01
2
5/
14
/2
01
2
5/
15
/2
01
2
5/
16
/2
01
2
5/
17
/2
01
2
% Compliance
Early Data –
Compliance with ICDSC Tool
ICDSC Completion Compliance : May 2-May 17, 2012
90
80
70
60
50
40
30
20
10
0
Date
Lessons Learned
• Using a step-wise approach to PDSA cycles allowed
us to build our knowledge base and confidence in
the ICDSC tool and educational roll-out
• The majority of education must be done prior to
implementation to sustain gains
• Ongoing listening, support and feedback must be
consistent if initiative is to be successful
Next Steps
• Ongoing Education
• Support completion of pain, sedation and delirium
assessment tools
• Audit compliance for completion of assessment tools
• Ongoing measurement of balancing measures (e.g.
rate of unplanned extubations)
Thank You