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 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 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 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

Pre-Survey Results – Knowledge regarding Delirium

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 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

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