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MHA/OHA Delirium Learning Network Collborative
January 24, 2019
Welcome
▪ In December 2015, the Minnesota and Ohio HENS began an intentional and active partnership to address delirium. This collaboration has been highly beneficial in the identification, development and dissemination of delirium tools and resources, as well as provide a greater learning opportunity for both states. Minnesota and Ohio have chosen to continue the collaboration as part of the HIIN work.
▪ Bi-Monthly webinars: Various topics will be reviewed by subject matter experts. Each webinar will consist of a Virtual Learning Session, followed by time for participants to ask questions, share challenges and connect with hospitals that may have found solutions and success.
▪ 2019 Collaborative: Deep Dive into the ABCDEF Bundle
▪ Please invite the appropriate individuals within your organization to participate in this collaborative, send their contact information to MHA or OHA.
**Please put the call on MUTE, not HOLD**
Sarah Pangarakis, MS, APRN, CCNS, CCRN
• Sarah Pangarakis, MS, APRN, CCNS, CCRN is an advanced practice clinical nurse specialist (CNS) in critical care implementing clinical evidence into practice to improve patient outcomes.
• Specific points of interest include Delirium, Donation After Circulatory Death, alcohol withdrawal, sepsis, and clinical outcomes such as pressure injuries, CLABSI, VAE, and CAUTI.
• Sarah has presented locally and nationally and has published on clinical topics such as clinical inquiry and evidence based practice, end tidal CO2 & clustering nursing interventions, and tailored messages for telemedicine home spirometry lung transplant patients.
• She has served on the MN NACNS Board of Directors as President, Treasurer, and planning committee member and was also an adjunct faculty member at Minnesota State University Moorhead School of Nursing. She has taught CNS students, undergraduate nursing students, and served as a clinical instructor for nursing students in Guatemala.
• In her free time Sarah enjoys Zumba, cheering on her husband and two sons at their hockey games, and camping.
Grenellie Walock, MSN, RN, CCRN
• Grenellie Walock, MSN, RN, CCRN has been an adult critical care nurse for over 12 years; 3 years of which are in a leadership and educator capacity. She has worked in various intensive care units including medical, surgical, cardiac surgery, and trauma units in Texas, North Carolina, New York, before moving to Minnesota.
• She is a member of house wide multidisciplinary Delirium Steering committee as well as Delirium nursing workgroup.
• She supported and facilitated implementation in critical care units of ABCDEF, ICU Liberation bundle and education for nursing staff members and new-hires.
• Ms. Walock received her MSN in 2018 with an emphasis on nursing education.
Implementing the “A” of the ABCDEF Bundle
A Strategy to Prevent Post ICU Syndrome and Liberate Patients from the ICU
Sarah Pangarakis MS, APRN, CCNS, CCRN
Grenellie Walock, MS, CCRN
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• Describe what is post ICU syndrome, how pain contributes to it, and why ICU Liberation is important.
• Explain what is the ABCDEF Bundle.
• List strategies to implement “A” section of the ABCDEF bundle to liberate patients from the ICU.
• Recall methods to monitor, sustain, and measure the “A” portion of the ABCDEF bundle.
Objectives
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Post ICU Syndrome
What is Post-ICU Syndrome?
“New or worsening impairments in physical, cognitive, or mental health status arising after, critical illness and persisting beyond acute care hospitalization.
The term can be applied to a survivor (PICS) or family member (PICS-F).”
8Elliot, R., et al. CritCare Med. 2014;42(12), 2518-2526
Needham, D.M. et al. CritCare Med. 2012; 40:509-509
Post ICU Syndrome
Post ICU Care
Family Patient
Psychological
Anxiety
Depression
Sleep Disorder
PTSD
Cognitive
Memory
Attention
Mental Processing
Physical
Weakness
Fatigue
Mobility Limitations
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Guatam, R., Yadav S., Kumar, R. (2017). Post-intensive Care Syndrome: an
Overview J Transl Int Med. 2017 Jun; 5(2): 90–92.
doi: 10.1515/jtim-2016-0016
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ICU Liberation
What is ICU Liberation?
• “Freeing patients from harmful effects of
pain, agitation, and delirium in the
ICU”
- Reduce long term consequences from an ICU stay.• Society of Critical Care Medicine,
• Long Term Consequence: Immobility, weakness, anxiety, insomnia, depression, attention, memory,
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Liberate Customers from the ICU!
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ABCDEF BUNDLE
Multidisciplinary Rounds
Valid Tools/Checklist
Prevention StrategiesPain
Agitation
Delirium
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ABCDEF BUNDLE
The ABCDEF Bundle
• The ABCDEF bundle is one way to align and coordinate care, which includes specific focus on delirium as a component of the overall care patients receive including sedation and pain medications, breathing machines, and mobilization.
• Incorporates the Pain, Agitation, Delirium (PAD) guidelines
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The ABCDEF BundleComponent
AAssessment and Management of Pain
BBoth Spontaneous Awakening Trials (SATs) aka “Sedation
Vacations” and Spontaneous Breathing Trials (SBTs)
CChoice of Analgesia and Sedation
DDelirium: Assess, Prevent, and Manage
EEarly Mobility and Exercise
FFamily Engagement and Empowerment
Individual Practitioners – Working in teams
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Bundle Element Primary
Accountability
Additional Team
Members Resp.
A Assess Pain & Analgesia RN MD, Pharm
B Breathing RT RN, MD, Pharm
C Coordination/Choice of Meds RN, RCP MD, Pharm
D Delirium RN RT, Pharm, MD,
PT
E Early Mobility PT/RN MD, RT
F Family and Patient RN HUC
The entire bundle begins with:
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Reduction
of
Sedation
Levels!
mcg, mg
Strive For - Outcomes
• Decrease ICU length of stay
• Decrease Delirium Prevalence
• Better Pain Control
• Less Agitation
• Decrease Ventilator Days
• Decrease LTACH Transfers
• Increase Mobility (i.e. maintain muscle mass)
• Better Quality of life post ICU hospitalization
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Analgesia and Pain AssessmentABCDEF Bundle
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Pain, Agitation, and Delirium (PAD) Guidelines
2013 Evidence
Based Practice
Guidelines
Assess
• Pain
• Agitation
• Delirium
Treat if present
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2018 Clinical Practice Guidelines
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• Use Valid Assessment Tool
• Physiological measure are NOT
enough (i.e. HR, BP, SPO2
• Proxy reporters of Pain
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Inadequate pain management has been associated with numerous complications including
- Nosocomial infections
- Increased duration of mechanical ventilation
- Delirium
- Anxiety
- Depression
- Immobility
PAIN causes Delirium!
Stolling, J. (2016). Medication Management to Ameliorate
Post–Intensive Care Syndrome AACN Advanced Critical Care Volume 27, Number 2, pp. 133-
140 DOI: http://dx.doi.org/10.4037/aacnacc2016931
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• “The treatment of pain with opiates in critically ill patients has been associated with an increased risk of delirium in some studies and a decreased risk of delirium in others.
• Opioids are the medication class of choice for treating pain in critically ill patients.
• The potential for the development of delirium highlights one of the many reasons why pain assessment in critically ill patients is so imperative”
Narcotics and Delirium
Stolling, J. (2016). Medication Management to Ameliorate
Post–Intensive Care Syndrome AACN Advanced Critical Care Volume 27, Number 2, pp. 133-
140 DOI: http://dx.doi.org/10.4037/aacnacc2016931
26
Implementation Strategies“A” of the ABCDEF
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Founded in 1954
353-bed community hospital in Robbinsdale, MN
Level I Trauma & Level II Pediatric serving NW MN
celebrated its 20th Anniversary
Comprehensive Stroke Center
Four Intensive Care Units
• Cardiovascular
Surgical
• Trauma Neuro
Surgical ICU
• Medical ICU
28
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• Form a team/Create a structure- Steering Committee
- Workgroup
- Champions
- Lead by nursing leadership
• Break the bundle up by sections to develop strategies/interventions
• Map out a plan
• Mass Education
• Implement as a full bundle
Implementation
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• Formed to answer bundle questions and sub work
Multidisciplinary Team
Pain Practice
Nurses
Intensivist
Pharmacists
Trauma Surgeon
Respiratory
Clinical Leadership
• Steering
Committee
• Workgroup
• Champions
• Critical Care
Committee
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CNS
• Ordersets
• Policy
• Practice/Education
• Ideation
• Literature
• Reports/Epic
• Leads Workgroup
ANMs
• Lead Champions (one RN champion per ICU)
• Newsletters
• Practice/Education
• Epic Changes/Request
• Participates in Workgroup
• Accountability
ICU Champions
• Change agents at the front line
• Feedback Source
• Clinical Ideas
• At elbow education
NM
• Lead Steering
• Set meetings
• Audits
• Keeps the Pace
• Clinical Input/Accountability
• Participates in Workgroup
Nursing Leadership
“A "Objectives
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Determine current state of overall Pain/Analgesic Determine
Educate and raise awareness of pain as part of ICU Liberation work via the ABCDEF bundle
Educate and raise
Incorporate pain into daily discussions (MD/RN Rounds and summary notes) Care Progression
Incorporate
Monitor/measure/communicate pain practicesMonitor/measure
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Timeline
Assess Current State
• How are the pain assessment/reassessments?
• How do we manage/treat pain?
• Do we treat pain first before we sedate?
• Do we consider pain a source of delirium?
• What alternatives do we use for pain management?
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Pain Assessments 2018
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Reassessment 2018
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Pain Assessment Documentation (at the point of care)
• Opioid infusions achieve stable blood levels opioids
- without the peaks and troughs associated with intermittent regimes.
• Addresses “assume pain present”
• Potential to overmedicate.
• IV Push
• Peak/troughs
• Potential to under-medicate
• Hard to assess pain with sedation present
• Symptom driven –less overmedicate
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Treatment: IV Push vs Continuous InfusionIt’s controversial
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Increase Fentanyl use over Dilaudid
Acute/Shorter Acting
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Pain Accordion and APP
Udita, N., Pramila, B., Sanjay, C. (2008) Assessment of sedation and analgesia in mechanically
ventilated patients in intensive care unit. Indian Journal of Anesthesia. 52(5) p 519
Interventions
• Educate Treat Pain First
• Multimodal Pain Panels
• Quiet Time
• Ketamine
• FASTER HUG BID
• Monitoring- Real Time
- Collectively
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ABCEDF Education Bundle
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Always Treat Pain 1st! See Guidelines
Critical Care, 2002
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Best Practice! Treat Pain First
Intubation:
analgesic 1st then sedative
Extubation:
wean sedative 1st then analgesic
*** Low dose continuous narcotic infusion is synergistic to sedative infusion and may result in better pain control, less sedation, and possibly reduced incidence of delirium.
Pain and Sedation: Treat Pain First!
Ask ourselves:
Do we use IV push PRN enough?
Are our patients agitated and we
increase sedation or do we treat
pain first?
Would low dose continuous opioid
infusion be better?
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Pain vs Agitation
Treatment of Pain (cont.)You may not need opioids…
• Non-opioid analgesics - Decreases the amount of opioids administered
- Eliminate need for opioids altogether
- Decrease opioid-related side effects
• Agents:- Acetaminophen (PO/IV)
- Ketorolac (Toradol)
- Ibuprofen
- Gabapentin
- Ketamine (IV)
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Multimodal Pain Management Panels
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Sample Order Set
Opioid Tolerant Multimodal
Pain Management Panel
Ketamine and Lidocaine for Trauma• Subanesthetic doses for rib
fracture/bone pain
• Wean off opioids
• Convert to PO or long acting quicker
• Enhances early mobility
• Deep Breathing/Oxygenation
• Transfer out of ICU
• Ketamine on MS trauma and ICU
• Lidocaine when Ketamine not available
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Ketamine Order Set
Nonpharmacological Pain Interventions
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Aromatherapy Healing Touch
Pet Therapy
Music Therapy
Family/Companionship
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Quiet Time in the ICU
1 Nightingale, F. (1969). Notes on nursing. New York: Dover.
2 Watson, J. (2008). Nursing: The Philosophy and Science of Caring
(Revised Edition ed.). Boulder, CO: University Press of Colorado.
• Occurs during the hours of 1:30 – 3:30pm in all critical care areas
• Why Quiet Time?- Noise can impair healing because it disturbs sleep
cycles, increases heart rate and blood pressure as a stress response, and contributes to anxiety and agitation1. These can prolong your recovery and extend the length of time you spend in the hospital2.
Quiet Time in the ICU
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• Mnemonic used to progress patient care
• Incorporated in bedside MD/RN Rounds
• RN end of shift summary note
• “A” = analgesia, addresses pain management
FASTER HUGS BID Template
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Summary “A” Strategies
• ICU Liberation Champions
• ICU Liberation Work Group/Steering Committee
• Recognizing Pain vs Agitation (APP)
• “Treat Pain First” motto
• Pain Panels
• Fentanyl over longer acting
• Pain/ABCDEF Accordions
• Quiet Time
• FASTER HUGBID
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Monitoring, Measuring, Sustaining
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Are we treating and managing pain effectively?
• Data from the ABCDEF
Bundle and Pain
Accordions
• Continuous pain infusion
or PRN medications
ordered if patient at
comfort goal
• Consider pain meds first
when RASS score
increases (e.g. patient
becomes agitated) prior to
increasing sedation
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Daily Audits
**Currently, this is a manual process. ICU
leaders audit each patient daily using the
ABCDEF and pain accordions in Epic.
Percent %
bundle compliance
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Sample of “ABCDEF
Bundle” accordion
in Epic
Pain management
can also be viewed in
“Pain/PCA/Epidural”
accordion
61
Dashboard
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• Follow-up is done with RNs, RT leadership, MDs, etc. via e-mail or in-person
• Each ICU have different focus areas based on which component of the bundle lacks compliance or needs extra support – refer to dashboard
• Addressed on a unit-level at monthly QMS Rounds with frontline team and units managers, ICU director, quality team, and executive leadership
• Report out at monthly multidisciplinary Critical Care Committee meetings
Accountability
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Electronic Report
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• Over 90% with pain reassessments
• Pain Panels
• RASS within goal- Decreased RASS levels
• ABCDEF Bundle Accordion
• Decreased VAE
• Decreased Pressure Injuries
• CAUTI SIR < 1.023 SUR 1.08
• Increased Mobility
• Quality Board Discussions
Successes
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• Pain Assessments
• Add RASS to Pain Accordion and Pain to ABCDEF Accordion
• Pain vs Agitation – Treat pain first
• Enhancing Pain Scales- APP drop down options
- Protocol approach to pain
- CPOT?
• Move to complete electronic report vs. manual
Next Steps
Questions
2019 Schedule
▪ Fourth Thursday of every month*
• January 24, 2019• March 28, 2019• May 23, 2019• July 25, 2019• September 26, 2019• November 21, 2019*
All calls are scheduled from 11:00-12:00 (CT)
Thank You
▪ Please invite the appropriate individuals within your organization to participate in this collaborative.
▪ CEU information will be emailed to all participants following the webinar.
▪ Thank you and have a wonderful day!
