ICU Pain Agitation Delirium Care Bundle Metrics

ICU Pain, Agitation, & Delirium Care Bundle Metrics: Measurement for Improvement 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, Pharm. D, FCCM; Kathleen Puntillo, RN, DNSc, FAAN; E. Wesley Ely, MD, MPH, FACP, FCCM; Céline Gélinas, RN, Ph. D; Joseph F. Dasta, MSc; Judy E. Davidson, DNP, RN; John W. Devlin, Pharm. D, 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, Ph. D, 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?

X Deep vs. Light Sedation of ICU Patients Pre-PAD Guidelines Post-PAD Guidelines

Integrated PAD Management Early Mobility Pain Management Sedation/ Agitation Spontaneou s Awakening Trials Spontaneo us Breathing Trials 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 EM ABC+E EM SAT/TS ABCDE MV ↓ 3 d LOS ↓ 4 d Mort ↓ 32% ICU LOS ↓ 1. 4 d Hosp LOS ↓ 3. 3 d ↓ 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 Assess pain ≥ 4 x/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 AGITATION Assess agitation, sedation ≥ 4 x/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 TREAT • Pharmacologic treatment: • Non-neuropathic pain IV opioids +/- non -opioid analgesics • Neuropathic pain gabapentin or carbamazepine, + IV opioids • S/p AAA repair, rib fractures thoracic 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 epidural PREVENT • 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 Compliance PAD Integration ICU PAD Care Bundle PAD Treatment 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 ≥ 4 x/shift • Demonstrate local compliance and implementation integrity over time in the use of ICU pain scoring systems • % of time sedation assessments are performed ≥ 4 x/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 receive pre -procedural analgesia therapy and/or non-pharmacologic interventions • % compliance with institutional-specific ICU pain management protocols • % 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 • % 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 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 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. , Q 1 -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. , Q 1 -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: • Power. Point 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