More Bang for Your Bundle: Implementing Routine Pain, Agitation, and Delirium (PAD) Care in the ICU Neil Roe, PharmD, BCCCP Clinical Pharmacy Specialist – Critical Care Baptist Health Medical Center Little Rock, AR AAHP Fall Seminar 2017

I have no conflicts of interest to disclose.

Pharmacist Objectives Define pain, agitation, and delirium (PAD) in the intensive care unit (ICU) Identify best practices for management of PAD Discuss the benefits of a care bundle in the ICU Design a process for implementation of a PAD care bundle

Technician Objectives Describe pain, agitation, and delirium (PAD) in the intensive care unit (ICU) Discuss the best practices for management of PAD Examine the benefits of a care bundle in the ICU Form a plan for implementation of a PAD care bundle

Complexity of PAD Reade mc, finfer s. N Engl J Med. 2014;370(5):444-54

Pain Complications Disease Invasive Devices Immobility Routine Care “An unpleasant sensory and emotional experience associated with actual or potential tissue damage.” Disease Invasive Devices Immobility Routine Care Complications Chronic pain Stress Sleep-loss Hyper-metabolism Impaired wound healing Impaired immune function Feelings of Helplessness Post-traumatic stress disorder Barr, et al. Crit Care Med. 2013;41(1):263-306.

Behavioral Pain Scale (BPS) Critical Care Pain Observation Tool (CPOT) Assessment of Pain Question: Can pain be accurately assessed in the ICU? Obstacles: Subjective, differs between individuals Self-reporting = GOLD standard Behavioral Pain Scale (BPS) Critical Care Pain Observation Tool (CPOT) Sigakis, et al. Crit Care Med. 2015;43(11):2468-78.

Options for Pain Non-neuropathic pain Neuropathic pain Acute pain IV Opioids Acute pain Gabapentin Carbamazepine Neuropathic pain NSAIDS Acetaminophen Ketamine Non-neuropathic pain Barr, et al. Crit Care Med. 2013;41(1):263-306

Pain - Summary Guideline Statement: “We suggest that pain be routinely monitored in all adult ICU patients.” Guideline Statement: “We recommend that IV opioids be considered as the first-line drug class of choice to treat non-neuropathic pain…” Guideline Statement: “Analgesia-first sedation should be used in mechanically ventilated adult ICU patients…” Barr, et al. Crit Care Med. 2013;41(1):263-306

Patient Population Intervention Outcomes Studied Patients needing mechanical ventilation for >24 hours Intervention Analgesia “Only” vs. Sedation Morphine IV push, verbal reassuring Haloperidol given for delirium Propofol x6 hours if still uncomfortable Outcomes Studied Primary: Days without mechanical ventilation (first 28 days) Secondary: Length of stay, accidental extubations, pneumonia Strøm, et al. Lancet. 2010;375(9713):475-80.

Strøm, et al. Lancet. 2010;375(9713):475-80.

Days off ventilator – 4.2 days ICU stay – 9.7 days Strøm, et al. Lancet. 2010;375(9713):475-80.

Review Question #1 1. Among those listed, which medication is the preferred option for acute pain in the ICU? Ketamine Acetaminophen Morphine Ketorolac

Photo: “Lumex Nightmare” by Ralph Sirianni Agitation “A syndrome of excessive motor activity, usually non-purposeful and associated with internal tension.” Sources Pain Hypoxia Withdrawal Hypoglycemia Delirium Hypotension Photo: “Lumex Nightmare” by Ralph Sirianni Reade, Crit Care. 1999;3(3):R35-R46. Barr, et al. Crit Care Med. 2013;41(1):263-306.

Assessment of Agitation https://coreem.net, accessed May 19, 2017 Riker, et al. Crit Care Med 1999;27:1325-1329

Options for Sedation Barr, et al. Crit Care Med. 2013;41(1):263-306. Benzodiazepines Propofol Dexmedetomidine Barr, et al. Crit Care Med. 2013;41(1):263-306.

Respiratory Depression Options for Sedation Midazolam Propofol Dexmedetomidine Amnesia X Analgesia Anticonvulsion Antiemesis Anxiolysis Hypnosis Sedation Bradycardia Hypotension Respiratory Depression Barr, et al. Crit Care Med. 2013;41(1):263-306.

Shehabi, et al. Am J Respir Crit Care Med. 2012;186(8):724-31.

Patient Population Comparison Outcomes Studied On mechanical ventilation Receiving continuous or intermittent sedation and/or analgesia Comparison Deeply sedated vs. Not deeply sedated Deeply sedated = RASS -5 to –3 within the first 48 hours Outcomes Studied The impact of sedation practices on: Time to extubation Delirium Mortality (180-day) Shehabi, et al. Am J Respir Crit Care Med. 2012;186(8):724-31.

Median time to extubation: 7.7 days vs. 2.4 days Shehabi, et al. Am J Respir Crit Care Med. 2012;186(8):724-31.

180-day Mortality Shehabi, et al. Am J Respir Crit Care Med. 2012;186(8):724-31.

Fraser, et al. Crit Care Med. 2013;41(9 Suppl 1):S30-8.

ICU Length of Stay Fraser, et al. Crit Care Med. 2013;41(9 Suppl 1):S30-8.

Duration of Mechanical Ventilation ICU Length of Stay Fraser, et al. Crit Care Med. 2013;41(9 Suppl 1):S30-8.

Agitation - Summary Guideline Statement: “Maintaining light levels of sedation in adult ICU patients is associated with improved clinical outcomes.” Guideline Statement: “We recommend either daily sedation interruption or a light target level of sedation be routinely used in mechanically ventilated adult ICU patients.” Guideline Statement: “The use of sedation scales, sedation protocols designed to minimize sedative use, and the use of nonbenzodiazepine medications are associated with improved ICU patient outcomes.” Barr, et al. Crit Care Med. 2013;41(1):263-306.

Review Question #2 2. Deep sedation in the ICU is associated with which of the following outcomes? Increased ICU length of stay Increased mortality Both A and B None of the above

Delirium & Inattention & & Disorganized Thinking “Sudden, severe confusion and rapid changes in brain function that occur with physical or mental illness.” Acute Change or Fluctuation in Mental Status & Inattention & & Disorganized Thinking Altered Level of Consciousness OR Delirium Barr, et al. Crit Care Med. 2013;41(1):263-306.

Delirium Complications Increased LOS Increased cost Increased time on ventilator Agitation Long term cognitive deficits Mortality Barr, et al. Crit Care Med. 2013;41(1):263-306. Reade mc, finfer s. N Engl J Med. 2014;370(5):444-54. Marra, et al. Crit Care Clin. 2017;33(2):225-243. Salluh, et al. BMJ. 2015;350:h2538.

Analysis of 28 studies p<0.001 Analysis of 28 studies p<0.001 Salluh, et al. BMJ. 2015;350:h2538.

Delirium Day Up to 80% 2 to 3 11 Assessed via: Confusion Assessment Method (CAM-ICU) Intensive Care Delirium Screening Checklist (ICDSC) Incidence of delirium during stay Average time of onset Number of risk factors present Up to 80% Day 2 to 3 11 Numbers worth noting Marra, et al. Crit Care Clin. 2017;33(2):225-243. Barr, et al. Crit Care Med. 2013;41(1):263-306.

“…Lorazepam was an independent risk factor for daily transition to delirium…” Pandharipande, et al. Anesthesiology. 2006;104(1):21-6.

Delirium – Risk Factors At Baseline (Non-Modifiable) During Stay (Modifiable) Dementia Coma Hypertension Benzodiazepines Alcoholism Narcotics Higher severity of illness Immobility Age Sleep deprivation Jackson p, khan, a. Crit Care Clin. 2015;31(3):589-603. Barr, et al. Crit Care Med. 2013;41(1):263-306.

Delirium Treatment Guideline Statement: “There is no published evidence that treatment with haloperidol reduces the duration of delirium.” Guideline Statement: “Atypical antipsychotics may reduce the duration of delirium.” (Level C) Barr, et al. Crit Care Med. 2013;41(1):263-306.

Delirium Prevention Guideline Statement: “We provide no recommendation for a pharmacologic delirium prevention protocol…” Guideline Statement: “Benzodiazepine use may be a risk factor for the development of delirium…” Guideline Statement: “We recommend performing early mobilization…to reduce the incidence and duration of delirium” Barr, et al. Crit Care Med. 2013;41(1):263-306.

Review Question #3 3. The 2013 PAD guidelines recommend which of the following agents for prevention of delirium? Haloperidol Lorazepam Ziprasidone None of the above

PAD Management PAD management presents many challenges A few specific strategies have demonstrated success Implementation and performance is inconsistent Barr, et al. Crit Care Med. 2013;41(1):263-306.

Complexity of PAD Reade mc, finfer s. N Engl J Med. 2014;370(5):444-54

Could an ICU care bundle be the answer? Complexity of PAD Simplicity Could an ICU care bundle be the answer? Reade mc, finfer s. N Engl J Med. 2014;370(5):444-54

ICU Care Bundle A care bundle usually consists of 3-5 interventions that when performed together: Produce better outcomes than when done individually Help ensure delivery of standards of care Allow for easier auditing to assess delivery of care Sepsis Ventilator Associated Pneumonia Catheter Associated Infections Continuing Education in Anaesthesia Critical Care & Pain, Volume 12, Issue 4, 1 August 2012, Pages 199–202

PAD Management Guideline Statement: “A successful strategy is to implement an evidence-based, institutionally-specific, integrated PAD protocol, and to assess, treat and prevent PAD, using an interdisciplinary team approach.” Guideline Statement: “For acutely hospitalized patients ventilated for more than 24 hours, we suggest protocols attempting to minimize sedation.” -2013 Guidelines for Management of PAD in Adult ICU Patients -2016 Guidelines for Liberation from Mechanical Ventilation Barr, et al. Crit Care Med. 2013;41(1):263-306. Ouellette, et al. Chest. 2017;151(1):166-180.

A B C D E F ABCDEF Care Bundle Assess, prevent, & manage pain Both SAT and SBT C Choice of analgesia and sedation D Delirium: Assess, prevent, manage E Early mobility and exercise F Family engagement and empowerment Iculiberation.org

Dale Cr, et al. Ann Am Thorac Soc. 2014;11:367-374

Design Patient Population Intervention Outcomes Studied Single center Before & after Patient Population Surgical/Trauma ICU On mechanical ventilation Intervention Hospital update of PAD protocol Emphasized: Increased assessment by nursing Reducing amount of sedation Pairing awakening and breathing trials Outcomes Studied Primary: Time on mechanical ventilation Secondary: Delirium, ICU & hospital LOS Dale Cr, et al. Ann Am Thorac Soc. 2014;11:367-374

Design Patient Population Intervention Outcomes Studied Single center Before & after Patient Population Surgical/Trauma ICU On mechanical ventilation Intervention Hospital update of PAD protocol Emphasized: Increased assessment by nursing Reducing amount of sedation Pairing awakening and breathing trials Outcomes Studied Primary: Time on mechanical ventilation Secondary: Delirium, ICU & hospital LOS *17.6% - reduction in time on mechanical ventilation *12.4% - reduction in ICU LOS *14% - reduction in hospital LOS *Represent statistically significant results Dale Cr, et al. Ann Am Thorac Soc. 2014;11:367-374

Barnes-Daly, et al. Crit Care Med. 2017;45(2):171-178.

Barnes-Daly, et al. Crit Care Med. 2017;45(2):171-178.

Barnes-Daly, et al. Crit Care Med. 2017;45(2):171-178.

From Idea to Initiative Find Opportunity Find Stakeholders Find Champions Commit to the Cause Getting off the ground…

Prepare to Present Healthcare equivalent of a “business plan” Define success & how you will measure it Master this presentation! Introduce/pitch this to multiple parties Nursing administration Hospital administration P&T committees, other physician groups as needed Secure approval and get to work

Rules from Start to Finish Make friends Know the roles of your stakeholders Don’t decide what hasn’t been discussed Be invested in YOUR plan, but be open to ideas Appreciate each step forward

Broadly Speaking… Create an “opt-out” protocol Set Expectations Convert them to Orders Educate Encourage & Enforce Create an “opt-out” protocol How will you put this protocol in motion? Order sets Written plan

One Step at a Time: A Is your pain scale appropriate? Create expectation for frequency / documentation Tip: EHR should prompt a response Evaluate current analgesic strategies If good, formalize them Collaborate to develop a “treatment pathway” Do not let sedation mask pain EHR = Electronic Health Record

One Step at a Time: B Awakening Breathing Define and detail performance Set a convenient time The default is “yes” Daily handoff to respiratory Breathing Expect daily handoff The default is “yes” Perform according to ATS / CHEST Chart the result ATS – American Thoracic Society

One Step at a Time: C Active Meds Drugs of Abuse Home Meds Are analgesics / sedatives in line with the bundle Were the previous 24 hours successful? Do they fit today’s care plan? Today’s organ function? Expectation for physician communication

One Step at a Time: D Prevent what is difficult to treat Screen Treat Prevent what is difficult to treat Screen once per shift using CAM-ICU or ICDSC Treat by removing, then treat by adding

One Step at a Time: E Enlist your physical / occupational therapists Assess the current approach to ventilated patients Determine feasibility of a new approach Create the expectation for movement www.hill-rom.com, accessed August 2017

One Step at a Time: F Family participation should be standard in the ICU Work to enact policies that allow: Family presence Family involvement in both decisions and management Benefits include: Staff accountability Physical / emotional comfort for the patient Reduction in post traumatic stress disorder Jones, et al. Crit Care. 2010;14:R168.

Negotiate Warranty Period From Plan to Protocol “Go-live” Date Negotiate Warranty Period Avenue for Feedback Go-live! Evaluate Progress

Final Thoughts 2013 2016 Present Future SCCM ATS/CHEST Your ICU Your Site Guidelines for PAD Guidelines Ventilator Liberation Obligation to Implement Best Practices Improved Patient Outcomes “Knowing the benefits of these strategies and choosing not to perform them is no different than withholding a course-altering, potentially life-saving medication therapy.”

More Bang for Your Bundle: Implementing Routine Pain, Agitation, and Delirium (PAD) Care in the ICU Neil Roe, PharmD, BCCCP Clinical Pharmacy Specialist – Critical Care Baptist Health Medical Center Little Rock, AR AAHP Fall Seminar 2017