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Using the Model for Improvement to implement the Critical-Care Pain Observation Tool in an adult intensive care unit.

ABSTRACT: Managing pain is challenging in the intensive care unit (ICU) as often patients are unable to self-report due to the effects of sedation required for mechanical ventilation. Minimal sedative use and the utilisation of analgesia-first approaches are advocated as best practice to reduce unwanted effects of oversedation and poorly managed pain. Despite evidence-based recommendations, behavioural pain assessment tools are not readily implemented in many critical care units. A local telephone audit conducted in April 2017 found that only 30% of Scottish ICUs are using these validated pain instruments. The intensive care unit (ICU) at Raigmore Hospital, NHS Highland, initiated a quality improvement (QI) project using the Model for Improvement (MFI) to implement an analgesia-first approach utilising a validated and reliable behavioural pain assessment tool, namely the Critical-Care Pain Observation Tool (CPOT). Over a six-month period, the project deployed QI tools and techniques to test and implement the CPOT. The process measures related to (i) the nursing staff's reliability to assess and document pain scores at least every four hours and (ii) to treat behavioural signs of pain or CPOT scores ≥ 3 with a rescue bolus of opioid analgesia. The findings from this project confirm that the observed trends in both process measures had reduced over time. Four hourly assessments of pain had increased to 89% and the treatment of CPOT scores ≥3 had increased to 100%.

SUBMITTER: Mascarenhas M

PROVIDER: S-EPMC6231094 | biostudies-other | 2018

REPOSITORIES: biostudies-other

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Using the Model for Improvement to implement the Critical-Care Pain Observation Tool in an adult intensive care unit.

Mascarenhas Mairi M Beattie Michelle M Roxburgh Michelle M MacKintosh John J Clarke Noreen N Srivastava Devjit D

BMJ open quality 20181009 4

Managing pain is challenging in the intensive care unit (ICU) as often patients are unable to self-report due to the effects of sedation required for mechanical ventilation. Minimal sedative use and the utilisation of analgesia-first approaches are advocated as best practice to reduce unwanted effects of oversedation and poorly managed pain. Despite evidence-based recommendations, behavioural pain assessment tools are not readily implemented in many critical care units. A local telephone audit c ...[more]

PMID: 30515466

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Project description:BackgroundPain assessment in brain-injured patients in the intensive care unit (ICU) is challenging and existing scales may not be representative of behavioral reactions expressed by this specific group. This study aimed to validate the French-Canadian and English revised versions of the Critical-Care Pain Observation Tool (CPOT-Neuro) for brain-injured ICU patients.MethodsA prospective cohort study was conducted in three Canadian and one American sites. Patients with a traumatic or a non-traumatic brain injury were assessed with the CPOT-Neuro by trained raters (i.e., research staff and ICU nurses) before, during, and after nociceptive procedures (i.e., turning and other) and non-nociceptive procedures (i.e., non-invasive blood pressure, soft touch). Patients who were conscious and delirium-free were asked to provide their self-report of pain intensity (0-10). A first data set was completed for all participants (n = 226), and a second data set (n = 87) was obtained when a change in the level of consciousness (LOC) was observed after study enrollment. Three LOC groups were included: (a) unconscious (Glasgow Coma Scale or GCS 4-8); (b) altered LOC (GCS 9-12); and (c) conscious (GCS 13-15).ResultsHigher CPOT-Neuro scores were found during nociceptive procedures compared to rest and non-nociceptive procedures in both data sets (p < 0.001). CPOT-Neuro scores were not different across LOC groups. Moderate correlations between CPOT-Neuro and self-reported pain intensity scores were found at rest and during nociceptive procedures (Spearman rho > 0.40 and > 0.60, respectively). CPOT-Neuro cut-off scores ≥ 2 and ≥ 3 were found to adequately classify mild to severe self-reported pain ≥ 1 and moderate to severe self-reported pain ≥ 5, respectively. Interrater reliability of raters' CPOT-Neuro scores was supported with intraclass correlation coefficients > 0.69.ConclusionsThe CPOT-Neuro was found to be valid in this multi-site sample of brain-injured ICU patients at various LOC. Implementation studies are necessary to evaluate the tool's performance in clinical practice.

Project description:BackgroundThe short-term and long-term consequences of the most frequent painful procedures performed in the ICU are unclear. This study aimed to identify the risk factors associated with pain-related discomfort perceived by critically ill patients during the whole ICU stay as self-reported by patients at the end of their ICU stay.MethodsThe study involved 34 ICUs. Adult patients who survived an ICU stay of 3 calendar days or more were eligible for inclusion. Discomforts, including the pain-related discomfort, were assessed using the French 18-item questionnaire on discomfort in ICU patients, the "Inconforts des Patients de REAnimation" (IPREA). Patients scored each item from 0 (minimal discomfort) to 10 (maximal discomfort). Associations between patient characteristics at ICU admission, life support therapies and main potentially painful procedures performed during the ICU stay and pain-related discomfort scores assessed at the end of the ICU stay were analyzed.ResultsPatients with complete IPREA questionnaires (n = 2130) were included. The median pain-related discomfort score was 3 (IQR 0-5). From the univariate analysis, pain-related discomfort scores were negatively correlated with age and positively correlated with ICU stay duration; surgical patients reported significant higher pain-related discomfort scores than medical patients; chest drain insertion, chest drain removal, use of bladder catheter, central venous catheter (CVC) insertion, complex dressing change, and intra-hospital transport were associated with pain-related discomfort scores. From the multivariate analyses using generalized estimating equations models, only age, chest drain removal, use of a bladder catheter, CVC insertion, and intra-hospital transport were the main risk factors associated with pain-related discomfort scores.ConclusionPatients who underwent chest drain removal, bladder catheter, CVC insertion, and intra-hospital transport during their ICU stay reported higher pain-related discomfort scores (with respect to the whole ICU stay and assessed at the end of their ICU stay) than patients who did not experience these events. This study may pave the way for further targeted studies aiming at investigating a causal link between these common procedures in the ICU and adult critically ill patients' perceptions of their ICU stay regarding recalled pain.Trial registrationClinicaltrials.gov Identifier NCT02442934, retrospectively registered on May 13, 2015.

Project description:Abstract Preterm birth is a risk factor for early experience of pain. Despite advances in neonatal care, evidence‐based knowledge of the importance of adequate pain management and strong international guidelines for assessment and treatment of neonatal pain, only 10% of sick term and preterm infants were assessed for pain and stress on a daily basis. The aim of this quality improvement (QI) project is evaluation of implemented guidelines for pain assessment and management, and increased parental involvement in a Norwegian single‐family room NICU. Method: The different steps of the project entailed translation of the English version of COMFORTneo, development and implementation of guidelines with flowcharts for pain management, and pain assessment certification of the interprofessional staff. Part two of the project is supervision of the interprofessional staff in parental involvement in stress‐ and painful procedures. Our study showed that one year after implementation, 88.8% of the COMFORTneo assessments were performed according to the pain management guidelines. The staff used the flowcharts to assess, treat and reassess pain and stress. There was a high interrater reliability with linearly weighted Cohen's kappa values ranging from 0.81 to 0.95, with a median of 0.90. In addition, our study showed increased parental involvement in procedures, from 50.3% before to 82.3% after the quality improvement project. The success of this quality improvement project is explained by systematic use of flowcharts and implemented guidelines for pain management, interprofessional collaboration, and cultural change agents. Theoretical lectures and practical bedside supervision to interprofessional staff increased parental involvement in stress‐ and painful procedures. The aim of this quality improvement (QI) project is evaluation of implemented guidelines for pain assessment and management and increased parental involvement in a Norwegian single‐family room (SFR) NICU. The main steps were translation and implementation of the COMFORTneo scale and development of flowcharts and pain management guidelines. The study showed high compliance to guidelines, high COMFORTneo assessment inter‐rater reliability, and increased parental involvement in procedures.

Dataset Information

Using the Model for Improvement to implement the Critical-Care Pain Observation Tool in an adult intensive care unit.

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Using the Model for Improvement to implement the Critical-Care Pain Observation Tool in an adult intensive care unit.

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