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A Quality Improvement Project to Increase Adherence to a Pain, Agitation, and Delirium Protocol in the Intensive Care
Wendy Yan1, Brett T Morgan, Peter Berry
1Wendy Yan, DNP, CRNA, is a Nurse Anesthetist at Duke Regional Hospital. Brett T. Morgan, DNP, CRNA, is Director of the Nurse Anesthesia Program and an assistant professor at Duke University School of Nursing. Peter Berry, MSN, RN, CNL, CCRN, is nurse manager at the intensive care unit of Duke Raleigh Hospital. Mary K. Matthys, BSN, RN, CCRN, is clinical lead at the intensive care unit of Duke Raleigh Hospital. Julie A. Thompson, PhD, is a research associate and a statistical consultant at Duke University School of Nursing. Benjamin A. Smallheer, PhD, RN, ACNP-BC, FNP-BC, CCRN, CNE, is lead faculty of the Adult-Gerontology Acute Care Nurse Practitioner Program at Duke University School of Nursing. He actively practices within the Critical Care Setting at Duke Raleigh Hospital and has expertise in Pulmonary Critical Care. His current areas of research interest are the care of the aging critical care population, the implementation of innovative educational strategies to prepare Nurse Practitioner students for entry to practice, and gender-associated incivility experienced by male nursing students in the academic environment.
Background:
In recent years, the incidence of delirium has grown to epidemic proportions in the intensive care setting with up to 80% of mechanically ventilated patients being affected. This can lead to adverse patient outcomes such as increased lengths of hospital stay, increased mortality rates, and increased long-term cognitive impairment.
Objectives:
The objective of this project is to determine whether a quality improvement project can increase adherence to an existing pain, agitation, and delirium (PAD) protocol for enhanced patient outcomes.
Methods:
Chart audits were conducted to determine baseline compliance, use of the PAD protocol was measured, and the type of medications administered to each mechanically ventilated patient was assessed. Using the Knowledge-to-Action framework, a multidisciplinary, multidimensional educational module was then developed and implemented that included an online tutorial, point-of-care reminders, written materials, and verbal coaching. A 3-month postimplementation chart audit was conducted to determine whether increased protocol competence was achieved.
Results:
Protocol use unexpectedly decreased from 74% to 41% (P < .01);however, compliance with medication recommendations did increase despite the decrease in use. Intravenous opioid use increased from 12% to 40% (P ≤ .001), whereas sedative propofol infusions decreased from 82% to 35% (P ≤ .001).
Conclusions:
The implementation of a multidimensional, multidisciplinary project was successful in increasing compliance to the clinical practice guidelines for the management of PAD in adult intensive care unit patients, despite a decrease in protocol use. This unanticipated decrease in protocol use indicates the need for additional research in this area. Future recommendations also include a review of the existing PAD protocol to determine whether revisions could be made to better suit the needs of the staff while also improving patient outcomes in the arena of delirium experienced during critical care stays.
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