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
COI Disclosures
No Commercial Affiliations....
Learning Objectives
• To become familiar with the elements of the ICU PAD Care
Bundle.
• To understand the synergistic benefits of applying the ICU
PAD Care Bundle elements in an integrated fashion.
• To learn how to implement the ICU PAD Care Bundle.
• To learn how to monitor the effectiveness of the ICU PAD
Care Bundle.
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. 2012 (In press)
2012 Pain, Agitation, and Delirium
Clinical Practice Guidelines
Why are they significant?
Deep vs. Light Sedation of ICU Patients
Pre-PAD Guidelines
Post-PAD Guidelines
Integrated PAD Management
Early
Mobility
Pain
Management
Spontaneous
Awakening
Trials
Spontaneous
Breathing
Trials
Sedation/
Agitation
Delirium
Prevention,
Treatment
The Path to
PAD Integration…
PAD Care
Bundle*
*Pain, Agitation, and Delirium Care Bundle
The Path to PAD Integration (cont.)
SAT/TS
SBT
ABC
ABC
EM
ABC+E
EM
SAT/TS
ABCDE
MV ↓ 3d
LOS ↓ 4d
Mort ↓ 32%
ICU LOS ↓ 1.4d
Hosp LOS ↓ 3.3d
↓ delirium
↑ FS @ d/c
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!
Implementing the ICU PAD Care Bundle
PAIN
ASSESS
TREAT
PREVENT
AGITATION
Assess pain ≥ 4x/shift & prn
Preferred pain assessment tools:
• Patient able to self-report 
NRS (0-10)
• Unable to self-report  BPS (312) 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
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
until @ target, then restart @ 50% of previous dose
• Administer pre-procedural
analgesia and/or nonpharmacologic 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
DELIRIUM
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
• 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
• 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
Challenges to Implementing
the ICU PAD Care Bundle
PAD
Assessment
PAD
PAD
Compliance
PAD
Integration
Treatment
ICU PAD
Care
Bundle
PAD
Prevention
Step 1: Implement Pain, Agitation, and
Delirium Monitoring Tools in the ICU
Anxiety
Pain
Delirium
Pain Assessment
Numerical Rating Scale* (NRS)
*NRS > 4 is significant
Pain Assessment
Behavioral Pain Scale* (BPS)
*BPS Range = 3-12, BPS > 6 is significant
Pain Assessment
Critical Care Pain Observation Tool* (CPOT)
*CPOT range = 0 – 8, CPOT > 3 is significant
Sedation Assessment
Richmond Agitation Sedation Scale* (RASS)
*RASS range = -5 to +4, target RASS = 0 to -2
Sedation Assessment
Sedation Agitation Scale* (SAS)
*SAS range = 1 to 7, target SAS = 3 to 4
Delirium Assessment
CAM-ICU
ICUdelirium.org
Delirium Assessment
Intensive Care Delirium Screening Checklist* (ICDSC)
*Delirium present if ICDSC > 4
Step 2: Incorporate PAD Assessments
into Daily ICU Care Plan
• What is the patient’s pain score and their
current analgesia regimen?
• What is the patient’s current and target
sedation scores, and their current sedation
regimen?
• What is the patient’s delirium score and what
are their delirium risk factors?
Step 3: Apply ICU Specific Pain, Agitation,
and Delirium Management Protocols
• Pain:
–
–
–
–
Assess and treat pain first, then sedate (analgo-sedation)
Treat significant pain: NRS ≥ 4, BPS ≥ 6, or CPOT ≥ 3
Use appropriate pain management strategies (patient specific)
Administer pre-procedural analgesia
• Agitation/Sedation:
– Minimize sedative use, avoid over-sedation (DSI or TSS→SAT)
– Sedation goals: patient is responsive, aware, and able to purposely follow
commands* (RASS = 0 to -2 or SAS = 3 to 4)
– Choose sedatives that minimize side effects (patient-specific)
• Delirium:
–
–
–
–
Optimize pain management
Reorient patient
D/C deliriogenic drugs
Treat with anti-psychotics (patient-specific)
*Performs 3 out of 5 commands: opens eyes, maintains eye contact,
squeezes hand, sticks out tongue, wiggles toes.
Step 4: Link to Other Strategies to Reduce the
Need for Medications, Improve Outcomes
• Link spontaneous awakening trials (SAT) to
spontaneous breathing trials (SBT)-facilitate
weaning from MV.
• Link SAT to early mobility and exercise (EM)
protocols-reduce delirium, improve strength.
• Implement environmental controls to protect
patients’ sleep-wake cycles-reduce delirium,
improve sleep.
PAD Interdisciplinary Team
Pharmacy
Champion
Physical
Therapy
Champion
Hospital
Administrators
RT Champion
RN Champion
MD Champion
Family
Integrated
Approach
to PAD
Patient
PAD Guideline Implementation
MD Champion!
PAD Implementation (%)
Interdisciplinary PAD
Stakeholder Team
ICU PAD Care Bundle
Implementation Using PDSA Cycles
PLAN
ACT
DO
STUDY
ICU PAD Care Bundle
Implementation Using PDSA Cycles
• Plan:
– Assume your plan is flawed from the beginning!
– Set expectations, solicit feedback from stakeholders (get provider buy in).
• Do:
– Test drive individual components on a small scale (pick the right environment).
– Try something out quickly over short period (i.e., 1 shift, 1 day, 1 week).
• Study:
– Collect data to measure compliance with your intervention (sample small
amounts on a frequent basis).
– Get feedback from beta-testers (what went well, what didn’t, and why?)
• Act:
– Use data to improve your process (i.e., iterative improvement).
– Share results with all stakeholders-post run charts of process, outcome
measures over time (↑transparency, buy-in).
– Retest and expand use when process is working!
ICU PAD Care Bundle
Measuring Performance
How do you know
if your ICU PAD Protocols
are working?
ICU PAD Care Bundle − Metrics
PAIN
ASSESS
TREAT
PREVENT
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
Qshift
• Demonstrate local compliance
and implementation integrity
over time in the use of ICU
delirium assessment tools
• % of time ICU patients are in
significant pain (ie, NRS ≥ 4,
BPS ≥ 6, or CPOT ≥ 3)
• % 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)
• % of time patients receive
pre-procedural analgesia
therapy and/or nonpharmacologic 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 institutionalspecific ICU delirium prevention
and treatment protocols
ICU PAD Care Bundle
Measuring Performance
• Process vs. Outcome Measures*:
– Process:
• Are you doing what you think you’re doing?
• Identify a process measure for each aspect of your
protocol that you’re going to implement.
– Outcome:
• Is what you’re doing achieving the desired outcome?
• Measure both good and bad outcomes.
*Measure and chart all process and outcome measures at baseline and over time.
ICU PAD Care Bundle
Measuring Performance-Pain Management
• Process measures:
– Measure frequency of NRS (self-report) or BPS/CPOT
assessments (self-report NA) (i.e., Q1-2 hr or less?).
– Measure inter-rater reliability with BPS/CPOT assessments (i.e.,
compare bedside nursing assessments to nurse educator
assessments-use real or mock patients).
– Measure % time patients receive analgesics within 30” of
identifying significant pain.
– Measure % of time patients receive pre-procedural analgesics.
• Outcome measures:
– Measure % time patients are in significant pain
(NRS > 4 or BPS > 6/CPOT > 3).
– Measure analgesic use in the ICU (↑ or ↓).
ICU PAD Care Bundle
Measuring Performance-Sedation Management
• Process measures:
– Measure frequency of RASS/SASS assessments (i.e., Q1-2 hr or
less?).
– Measure inter-rater reliability with RASS/SAS assessments (i.e.,
compare bedside nursing assessments to nurse educator
assessments-use real or mock patients)
– % of time patients are either optimally sedated or successfully
achieve target sedation levels during DSI trials (i.e, RASS = -2 – 0,
SAS = 3 – 4)
• Outcome measures:
– Overall incidence of light sedation of ICU patients over time
( or remains unchanged?).
– % failed attempts at SBTs, Early Mobility trials due to either over
or under sedation
– Measure sedative use in the ICU (↓ or no change?).
ICU PAD Care Bundle
Measuring Performance-Delirium Management
• Process measures:
– Frequency of CAM-ICU/ICDSC assessments (i.e., Qshift or less?).
– Inter-rater reliability with CAM-ICU/ICDSC assessments (i.e.,
compare bedside nursing assessments to nurse educator
assessments-use real or mock patients).
– % of time delirium is present in ICU patients (i.e., CAM-ICU is
positive or ICDSC ≥ 4).
– Types of sedatives used in delirious ICU patients (i.e., benzos vs.
non-benzos?).
– % of ICU patients receiving daily physical therapy, early mobility.
– % compliance with ICU sleep promotion strategies.
• Outcome measures:
– Overall incidence/prevalence and duration of delirium in ICU
patients over time.
ICU PAD Bundle Toolkit
• Web-based
• Educational Tools:
• PowerPoint presentations−PAD guideline staff education
• Instructional videos
– Bedside pain, sedation/agitation, and delirium assessments
– Early mobility techniques
• Implementation Tools:
•
•
•
•
Pocket cards−ICU PAD Care bundle, guideline recommendations
Apps for smart phone, tablets-monitoring tools, drug dosing guidelines
Templates-check lists, goals sheets
Sample protocols
Implementing the PAD Guidelines
Key Points
1. Routinely assess pain, sedation/agitation, and
delirium separately using validated tools.
2. Avoid deep sedation, let patients be interactive.
3. Integrate PAD management with SBT, Early Mobility,
Environmental Sleep Management.
4. Implement the PAD Care Bundle using an
interdisciplinary, team-based approach.
5. Measure what you’re doing, improve performance!
The ICU PAD Care Bundle