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Pain, Agitation, and Delirium Guidelines: Interprofessional Perspectives to Translate the Evidence
Juliane Jablonski1, Jaime Gray, Todd Miano
1Juliane Jablonski, DNP, RN, CCRN, CCNS, is a clinical nurse specialist in surgical critical care at the Hospital of the University of Pennsylvania for the past 7 years now in the role of a Critical Care Registered Nurse Systems Strategist for Penn Medicine, Philadelphia, Pennsylvania. Jaime Gray, PharmD, BCPS, is a clinical pharmacy specialist in surgical critical care at the Hospital of the University of Pennsylvania, Philadelphia. Todd Miano, PharmD, MSCE, is a clinical pharmacy specialist in surgical critical care at the Hospital of the University of Pennsylvania and postdoctoral fellow of Biostatistics and Epidemiology at the University of Pennsylvania, Philadelphia. Gretchen Redline, PharmD, BCPS, is a clinical pharmacy specialist in surgical critical care at the Hospital of the University of Pennsylvania, Philadelphia. Heather Teufel, PharmD, BCPS, is a clinical pharmacist in the emergency department at Chester County Hospital, Chester County, Pennsylvania. Tara Collins, ACNP, RN, is an acute care nurse practitioner in surgical critical care and director of Advanced Practice at Penn Presbyterian Medical Center, Philadelphia, Pennsylvania. Jose Pascual-Lopez, MD, PhD, FACS, is a trauma surgeon and critical care intensivist at the University of Pennsylvania and co -medical director for Surgical Critical Care at the Hospital of the University of Pennsylvania, Philadelphia. Martha Sylvia, PhD, MBA, RN, is a director of Population Health Analytics at Medical University of South Carolina, associate professor at the Medical University of South Carolina and College of Nursing, and adjunct faculty appointment at Johns Hopkins University School of Nursing, Baltimore, Maryland. Niels D. Martin, MD, FACS, FCCM, is a section chief of surgical critical care, program director for the Surgical Critical Care Fellowship Training Program, and assistant professor in the Department of Surgery at the University of Pennsylvania Perelman School of Medicine, Philadelphia.
Background:
Societal guidelines exist for the management of pain, agitation, and delirium (PAD) in critically ill patients. This contemporary practice aims for a more awake and interactive patient. Institutions are challenged to translate the interrelated multivariable concepts of PAD into daily clinical practice and to demonstrate improvement in quality outcomes. An interdisciplinary goal-directed approach shows outcomes in high-acuity surgical critical care during the early stages of implementation.
Methods:
This study was a prospective preintervention and postintervention design. A formal PAD clinical practice guideline targeting standardized assessment and "light" levels of sedation was instituted. All mechanically ventilated patients admitted to a 24-bed surgical intensive care unit (ICU) at an academic medical center during a 6-month period were included (3 months before and 3 months after implementation). Sedation and agitation were measured using the Richmond Agitation Sedation Scale (RASS), pain measured using a Behavioral or Numeric Pain Scale (NPS/BPS), and delirium using the Confusion Assessment Method for the Intensive Care Unit. Total ventilator days with exposure to continuous opioid or sedative infusions and total ICU days where the patient received a physical activity session exercising out of bed were recorded.
Results:
There were 106 patients (54 at preintervention and 52 at postintervention). Mean percentage of RASS scores between 0 to -1 increased from 38% to 50% postintervention (P < .02). Mean percentage of NPS/BPS scores within the goal range (<5 for BPS and <3 for NPS) remained stable, 86% to 83% (P = .16). There was a decrease in use of continuous narcotic infusions for mechanically ventilated patients. This was reported as mean percentage of total ventilator days with a continuous opioid infusing: 65% before implementation versus 47% after implementation (P < .01). Mean percentage of ICU days with physical activity sessions increased from 24% to 41% (P < .001). Overall mean ventilator-free days and ICU length of stay were 5.4 to 4.5 days (P = .29) and 11.75 to 9.5 days (P = .20), respectively.
Conclusion:
Measureable patient outcomes are achievable in the early stages of PAD guideline initiatives and can inform future systems-level organizational change. Pain, agitation, and delirium assessment tools form the foundation for clinical implementation and evaluation. High-acuity surgical critical care patients can achieve more time at goal RASS, decreased ventilator days, and less exposure to continuous opioid infusions, all while maintaining stable analgesia.
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