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Pain, Sedation and Delirium Collaborative. Critical Care Unit May 28-29 th , 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 - PowerPoint PPT Presentation
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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
10
20
30
40
50
60
70
80
90
100
Not Comfortable Comfortable Extremely Comfortable
Per
cen
tag
e o
f R
esp
on
dan
ts (
%)
Pain Sedation Delirium
Pre-Survey Results – Knowledge regarding Delirium
Delirium - Knowledge Level
0
10
20
30
40
50
60
70
80
90
100
Signs and Symptoms of Delirium Identification of Appropriate Strategiesto prevent Delirium
Identification of AppropriateInterventions for paients with delirium
Per
cen
tag
e o
f R
esp
on
dan
ts (
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
0
10
20
30
40
50
60
70
80
90
Date
% C
ompl
ianc
e
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