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 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

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

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, PT

Ad 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

Changes Tested

PDSA Cycle #6 Educate a group of staff Using Pain, Sedation and Delirium Presentation

GO LIVE – May 3 rd , 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 Scores On Ventilated patients during daily goal rounds during 1 shift

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 Results Pain, Sedation and Delirium

Comfort Level when Assessing Patients for Pain, Sedation and Delirium

100 90 80 70 60 50 40 30 20 10 0 Not Comfortable Comfortable Pain Sedation Delirium Extremely Comfortable

Pre-Survey Results – Knowledge regarding Delirium

Delirium - Knowledge Level

100 90 80 30 20 10 0 70 60 50 40 Signs and Symptoms of Delirium Identification of Appropriate Strategies to prevent Delirium Identification of Appropriate Interventions for paients with delirium 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

Results Revised 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 26 th , 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

90 80 70 60 50 40 30 20 10 0 5/ 2/ 20 12 5/ 3/ 20 12 5/ 4/ 20 12 5/ 5/ 20 12 5/ 6/ 20 12 5/ 7/ 20 12 5/ 8/ 20 12 5/ 9/ 20 12 5/ 10 /2 01 2 5/ 11 /2 01 2 5/ 12 /2 01 2 5/ 13 /2 01 2 5/ 14 /2 01 2 5/ 15 /2 01 2 5/ 16 /2 01 2 5/ 17 /2 01 2

Date

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