1. Pain, Sedation and Delirium Collaborative
Critical Care Unit
May 28-29th, 2012

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. Pre-Survey Results Pain, Sedation and Delirium

11. Pre-Survey Results – Knowledge regarding Delirium

12. 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 ed to all staff
members for review

13. 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

14. 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)

15. 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

16. Early Data – Compliance with ICDSC Tool

17. 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

18. 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)

19. Thank You