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

• 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

• Evidenced based “ABCDE” bundle representing an integrated and inter- professional approach to the management of mechanically ventilated patients

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, PTAd 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

PDSA Cycle #6 Educate a group of staffUsing 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 ScoresOn Ventilated patients during daily goal rounds during 1 shift

Changes Tested

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 ResultsPain, Sedation and DeliriumComfort Level when Assessing Patients for Pain, Sedation and Delirium

0

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Not Comfortable Comfortable Extremely Comfortable

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%)

Pain Sedation Delirium

Pre-Survey Results – Knowledge regarding Delirium

Delirium - Knowledge Level

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Signs and Symptoms of Delirium Identification of Appropriate Strategiesto prevent Delirium

Identification of AppropriateInterventions for paients with delirium

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f R

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n=

23)

Extremely Knowldgeable Knowledgeable 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

ResultsRevised 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 Anti-

psychotic 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

Early Data –Compliance with ICDSC Tool

ICDSC Completion Compliance : May 2-May 17, 2012

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Date

% C

ompl

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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