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Results of implementing a pain management algorithm in intensive care unit patients: The impact on pain assessment, length of stay, and duration of ventilation. J Crit Care 2016; 36:207-211. [PMID: 27546773 DOI: 10.1016/j.jcrc.2016.07.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 06/27/2016] [Accepted: 07/11/2016] [Indexed: 11/24/2022]
Abstract
PURPOSE This study aimed to measure the impact of implementing a pain management algorithm in adult intensive care unit (ICU) patients able to express pain. No controlled study has previously evaluated the impact of a pain management algorithm both at rest and during procedures, including both patients able to self-report and express pain behavior, intubated and nonintubated patients, throughout their ICU stay. MATERIALS AND METHODS The algorithm instructed nurses to assess pain, guided them in pain treatment, and was implemented in 3 units. A time period after implementing the algorithm (intervention group) was compared with a time period the previous year (control group) on the outcome variables: pain assessments, duration of ventilation, length of ICU stay, length of hospital stay, use of analgesic and sedative medications, and the incidence of agitation events. RESULTS Totally, 650 patients were included. The number of pain assessments was higher in the intervention group compared with the control group. In addition, duration of ventilation and length of ICU stay decreased significantly in the intervention group compared with the control group. This difference remained significant after adjusting for patient characteristics. CONCLUSION Several outcome variables were significantly improved after implementation of the algorithm compared with the control group.
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Reardon DP, Anger KE, Szumita PM. Pathophysiology, assessment, and management of pain in critically ill adults. Am J Health Syst Pharm 2016; 72:1531-43. [PMID: 26346209 DOI: 10.2146/ajhp140541] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
PURPOSE The pathophysiology of pain in critically ill patients, the role of pain assessment in optimal pain management, and pharmacologic and nonpharmacologic strategies for pain prevention and treatment are reviewed. SUMMARY There are many short- and long-term consequences of inadequately treated pain, including hyperglycemia, insulin resistance, an increased risk of infection, decreased patient comfort and satisfaction, and the development of chronic pain. Clinicians should have an understanding of the basic physiology of pain and the patient populations that are affected. Pain should be assessed using validated pain scales that are appropriate for the patient's communication status. Opioids are the cornerstone of pain treatment. The use of opioids, administered via bolus dosing or continuous infusion, should be guided by patient-specific goals of care in order to avoid adverse events. A multimodal approach to pain management, including the use of regional analgesia, may improve patient outcomes and decrease opioid-related adverse events, though there are limited relevant data in adult critically ill patient populations. Nonpharmacologic strategies have been shown to be effective adjuncts to pharmacologic regimens that can improve patient-reported pain intensity and reduce analgesic requirements. Analgesic regimens need to take into account patient-specific factors and be closely monitored for safety and efficacy. CONCLUSION Acute pain management in the critically ill is a largely underassessed and undertreated area of critical care. Opioids are the cornerstone of treatment, though a multimodal approach may improve patient outcomes and decrease opioid-related adverse events.
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Affiliation(s)
- David P Reardon
- David P. Reardon, Pharm.D., BCPS, is Multispecialty Care Clinical Pharmacist, Department of Pharmacy, Yale-New Haven Hospital, New Haven, CT. Kevin E. Anger, Pharm.D., BCPS, is Clinical Pharmacy Specialist-Critical Care; and Paul M. Szumita, Pharm.D., BCPS, is Clinical Pharmacy Practice Manager, Department of Pharmacy, Brigham and Women's Hospital, Boston, MA.
| | - Kevin E Anger
- David P. Reardon, Pharm.D., BCPS, is Multispecialty Care Clinical Pharmacist, Department of Pharmacy, Yale-New Haven Hospital, New Haven, CT. Kevin E. Anger, Pharm.D., BCPS, is Clinical Pharmacy Specialist-Critical Care; and Paul M. Szumita, Pharm.D., BCPS, is Clinical Pharmacy Practice Manager, Department of Pharmacy, Brigham and Women's Hospital, Boston, MA
| | - Paul M Szumita
- David P. Reardon, Pharm.D., BCPS, is Multispecialty Care Clinical Pharmacist, Department of Pharmacy, Yale-New Haven Hospital, New Haven, CT. Kevin E. Anger, Pharm.D., BCPS, is Clinical Pharmacy Specialist-Critical Care; and Paul M. Szumita, Pharm.D., BCPS, is Clinical Pharmacy Practice Manager, Department of Pharmacy, Brigham and Women's Hospital, Boston, MA
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Gélinas C. Pain assessment in the critically ill adult: Recent evidence and new trends. Intensive Crit Care Nurs 2016; 34:1-11. [DOI: 10.1016/j.iccn.2016.03.001] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2016] [Indexed: 10/22/2022]
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Jung B, Daurat A, De Jong A, Chanques G, Mahul M, Monnin M, Molinari N, Jaber S. Rapid response team and hospital mortality in hospitalized patients. Intensive Care Med 2016; 42:494-504. [DOI: 10.1007/s00134-016-4254-2] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2015] [Accepted: 01/28/2016] [Indexed: 11/24/2022]
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Abstract
OBJECTIVES The aim of this article is to expose common myths and misconceptions regarding pain assessment and management in critically ill patients that interfere with effective care. We comprehensively review the literature refuting these myths and misconceptions and describe evidence-based strategies for improving pain management in the ICU. DATA SOURCES Current peer-reviewed academic journals, as well as standards and guidelines from professional societies. STUDY SELECTION The most current evidence was selected for review based on the highest degree of supportive evidence. DATA EXTRACTION Data were obtained via medical search databases, including OvidSP, and the National Library of Medicine's MEDLINE database via PubMed. DATA SYNTHESIS After a comprehensive literature review, conclusions were drawn based on the strength of evidence and the most current understanding of pain management practices in ICU. CONCLUSIONS Myths and misconceptions regarding management of pain in the ICU are prevalent. Review of current evidence refutes these myths and misconceptions and provides insights and recommendations to ensure best practices.
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Ambrogi V, Tezenas du Montcel S, Collin E, Coutaux A, Bourgeois P, Bourdillon F. Care-related pain in hospitalized patients: severity and patient perception of management. Eur J Pain 2015; 19:313-21. [PMID: 25055764 DOI: 10.1002/ejp.549] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Hospitalized patients commonly undergo painful procedures, but little is known about care-related pain (CRP) in the overall population of inpatients. We conducted a cross-sectional 1-day survey to assess the prevalence and characteristics of CRP and its management in all units of a university hospital in Paris and determined the factors linked to severe CRP. METHODS All patients who were able to communicate and were hospitalized for at least 24 h but not in a day-care or neonatal unit were included. RESULTS From 938 patients who completed the questionnaire, 554 patients reported pain within the previous 24 h, for a 59% prevalence of pain, and 540 (58%) had experienced CRP in the previous 15 days (51% males; mean [SD] age 54 [18] years). Of 907 procedures, 330 (37%) resulted in severe pain. The most-often reported painful procedures were vascular punctures and patient mobilization. Severe CRP was associated with long hospitalization; non-vascular invasive punctures, catheterization, mobilization or radiological examination; or pain during the previous 24 h due to surgery or treatment. Only half of the patients declared that they had received information regarding the painful procedure. Treatment for pain was proposed and delivered in less than one quarter of cases. CONCLUSIONS Our results of a survey of pain management in hospitalized patients relate to a wide variety of medical conditions and procedures. Health-care workers should be more systematic in managing CRP, and attention should be paid to patients at greatest risk of severe CRP.
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Affiliation(s)
- V Ambrogi
- Public Health Department, Pitié-Salpêtrière Hospital, Paris, France
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57
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Robleda G, Roche-Campo F, Sendra MÀ, Navarro M, Castillo A, Rodríguez-Arias A, Juanes-Borrego E, Gich I, Urrutia G, Nicolás-Arfelis JM, Puntillo K, Mancebo J, Baños JE. Fentanyl as pre-emptive treatment of pain associated with turning mechanically ventilated patients: a randomized controlled feasibility study. Intensive Care Med 2015; 42:183-91. [PMID: 26556618 DOI: 10.1007/s00134-015-4112-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2015] [Accepted: 10/17/2015] [Indexed: 02/01/2023]
Abstract
PURPOSE To compare pain incidence and changes in pain scores with fentanyl versus placebo as pre-emptive treatment during turning and 30 min post-turning in mechanically ventilated critically ill patients. METHODS We performed a randomized, double-blind, parallel-group, placebo-controlled clinical trial in the intensive care unit of a university hospital. Seventy-five mechanically ventilated patients were randomized to an intervention group (fentanyl) or a control group (placebo). Patients in the intervention group received 1 µg/kg (medical patients) or 1.5 µg/kg (surgical patients) of fentanyl 10 min before turning. Pain indicators were assessed using the behavioral pain scale. Safety was assessed by determining the frequency and severity of pre-defined adverse events. Pain was evaluated at rest (T0), at turn start and end (T1 and T2) and at 5, 15 and 30 min post-turning (T3, T4 and T5). RESULTS The two groups had similar baseline characteristics. The area under the curve for BPS values was significantly smaller in the fentanyl group than in the control group [median and interquartile range (IQR): 132 (108-150) vs. 147 (125-180); p = 0.016, respectively]. Nineteen non-serious adverse events were recorded in 14 patients, with no significant between-group differences (23 % fentanyl group vs. 14 % control group; p = 0.381). CONCLUSIONS These results suggest an intravenous bolus of fentanyl of 1 µg/kg for medical patients or 1.5 µg/kg for surgical patients reduces the incidence of turning-associated pain in critically ill patients on mechanical ventilation. ClinicalTrials.gov: NCT 01950000.
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Affiliation(s)
- Gemma Robleda
- Department of Nursing Research, Hospital de la Santa Creu i Sant Pau, Sant Antoni Mª Claret, 167, 08025, Barcelona, Spain.
| | - Ferran Roche-Campo
- Intensive Care Unit, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Intensive Care Unit, Hospital de Tortosa Verge de la Cinta, Tarragona, Spain
| | | | - Marta Navarro
- Intensive Care Unit, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Ana Castillo
- Intensive Care Unit, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Ainhoa Rodríguez-Arias
- Department of Pharmacy, Research Pharmacist, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Elena Juanes-Borrego
- Department of Pharmacy, Research Pharmacist, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Ignasi Gich
- Department of Clinical Epidemiology and Public Health, IIB Sant Pau, Barcelona, Spain
- CIBERESP, Barcelona, Spain
- Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Gerard Urrutia
- Department of Clinical Epidemiology and Public Health, IIB Sant Pau, Barcelona, Spain
- CIBERESP, Barcelona, Spain
| | | | - Kathleen Puntillo
- Department of Physiological Nursing, School of Nursing, University of California, San Francisco, USA
| | - Jordi Mancebo
- Intensive Care Unit, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Josep E Baños
- Department of Experimental and Health Sciences, Universitat Pompeu Fabra, Barcelona, Spain
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de Lattre S, de Jong A, Gniadek C, Carr J, Tondut G, Conseil M, Cissé M, Jaber S, Chanques G. Douleur en réanimation : problématiques soignantes. MEDECINE INTENSIVE REANIMATION 2015. [DOI: 10.1007/s13546-015-1114-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Liu Y, Li L, Herr K. Evaluation of Two Observational Pain Assessment Tools in Chinese Critically Ill Patients. PAIN MEDICINE 2015; 16:1622-8. [DOI: 10.1111/pme.12742] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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De Jong A, Jaber S. From weaning theory to practice: implementation of a quality improvement program in ICU. Intensive Care Med 2015; 41:1847-50. [PMID: 26156110 DOI: 10.1007/s00134-015-3960-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Accepted: 06/29/2015] [Indexed: 11/25/2022]
Affiliation(s)
- Audrey De Jong
- Intensive Care Unit and Transplantation, Critical Care and Anesthesia Department (DAR B), Hôpital Saint-Éloi, CHU de Montpellier, 80, Avenue Augustin Fliche, INSERM U1046, 34295, Montpellier Cedex 5, France.
| | - Samir Jaber
- Intensive Care Unit and Transplantation, Critical Care and Anesthesia Department (DAR B), Hôpital Saint-Éloi, CHU de Montpellier, 80, Avenue Augustin Fliche, INSERM U1046, 34295, Montpellier Cedex 5, France.
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Bae KH, Jeong IS. [Pain perception of nurses and pain expression of patients in critical care units]. J Korean Acad Nurs 2015; 44:437-45. [PMID: 25231809 DOI: 10.4040/jkan.2014.44.4.437] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
PURPOSE This study was done to identify pain perception (P-PER) by nurses and pain expression (P-EXP) by patients in critical care units (ICUs) and degree of agreement between nurses' P-PER and patients' P-EXP. METHODS Nurses' P-PER was measured with a self-administered questionnaire completed by 99 nurses working in ICUs during May, 2013. Patients' P-EXP was measured with the Critical Care Non-Verbal Pain Scale through observations of 31 ICU patients during nine nursing procedures (NPs) performed between May and July, 2013. RESULTS Nurses' P-PER was from 4.49 points for nasogastric tube (NGT) insertion to 0.83 for blood pressure (BP) measurement based on a 9-point scale, Patients' P-EXP was 4.48 points for NGT to 0.18 for BP measurement based on a 10-point scale. Eight NPs except oral care showed higher scores for nurses' P-PER than for patients' P-EXP. Position change (p=.019), subcutaneous injection (p<.001), blood sugar test (p<.001), and BP measurement (p<.001) showed significant differences between nurses' P-PER and patients' P-EXP. CONCLUSION Nasogastric tube (NGT) insertion was scored highest by both nurses and patients. Eight NPs except 'oral care' showed nurses' P-PER was higher or similar to patients' P-EXP, which indicates that nurses may overestimate procedural pain experienced by patients.
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Affiliation(s)
- Kyung Hee Bae
- Department of Nursing, Pusan National University Hospital, Busan, Korea
| | - Ihn Sook Jeong
- College of Nursing, Pusan National University, Yangsan, Korea.
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63
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Chanques G, Nelson J, Puntillo K. Five patient symptoms that you should evaluate every day. Intensive Care Med 2015; 41:1347-50. [PMID: 25758669 DOI: 10.1007/s00134-015-3729-x] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 03/02/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Gérald Chanques
- Department of Anesthesiology and Critical Care Medicine, University of Montpellier Saint Eloi Hospital, Montpellier, France,
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64
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Chanques G, Pohlman A, Kress JP, Molinari N, de Jong A, Jaber S, Hall JB. Psychometric comparison of three behavioural scales for the assessment of pain in critically ill patients unable to self-report. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:R160. [PMID: 25063269 PMCID: PMC4220092 DOI: 10.1186/cc14000] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Accepted: 06/19/2014] [Indexed: 01/02/2023]
Abstract
Introduction Pain assessment is associated with important outcomes in ICU patients but remains challenging, particularly in non-communicative patients. Use of a reliable tool is paramount to allow any implementation of sedation/analgesia protocols in a multidisciplinary team. This study compared psychometric properties (inter-rater agreement primarily; validity, responsiveness and feasibility secondarily) of three pain scales: Behavioural Pain Scale (BPS/BPS-NI, that is BPS for Non-Intubated patients), Critical Care Pain Observation Tool (CPOT) and Non-verbal Pain Scale (NVPS), the pain tool routinely used in this 16-bed medical ICU. Methods Pain was assessed by at least one of four investigators and one of the 20 bedside nurses before, during and 10 minutes after routine care procedures in non-comatose patients (Richmond Agitation Sedation Scale ≥ -3) who were unable to self-report their pain intensity. The Confusion Assessment Method for the ICU was used to assess delirium. Non-parametric tests were used for statistical analysis. Quantitative data are presented as median (25th to 75th). Results A total of 258 paired assessments of pain were performed in 30 patients (43% lightly sedated, 57% with delirium, 63% mechanically ventilated). All three scales demonstrated good psychometric properties. However, BPS and CPOT exhibited the best inter-rater reliability (weighted-κ 0.81 for BPS and CPOT) and the best internal consistency (Cronbach-α 0.80 for BPS, 0.81 for CPOT), which were higher than for NVPS (weighted-κ 0.71, P <0.05; Cronbach-α 0.76, P <0.01). Responsiveness was significantly higher for BPS compared to CPOT and for CPOT compared to NVPS. For feasibility, BPS was rated as the easiest scale to remember but there was no significant difference in regards to users’ preference. Conclusions BPS and CPOT demonstrate similar psychometric properties in non-communicative intubated and non-intubated ICU patients. Electronic supplementary material The online version of this article (doi:10.1186/cc14000) contains supplementary material, which is available to authorized users.
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Gélinas C, Chanques G, Puntillo K. In pursuit of pain: recent advances and future directions in pain assessment in the ICU. Intensive Care Med 2014; 40:1009-14. [PMID: 24797682 DOI: 10.1007/s00134-014-3299-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2014] [Accepted: 04/09/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Céline Gélinas
- Ingram School of Nursing, McGill University, Montreal, Quebec, Canada
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Bender BG. Pain Control in the Intensive Care Unit: New Insight into an Old Problem. Am J Respir Crit Care Med 2014; 189:9-10. [DOI: 10.1164/rccm.201311-2059ed] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
- Bruce G. Bender
- The Center for Health PromotionNational Jewish HealthDenver, Colorado
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Chanques G, Jaber S. [Unexpected progress of an old intensive care therapy, oxygen: towards more comfort and less mechanical ventilation…]. Rev Mal Respir 2013; 30:605-8. [PMID: 24182647 DOI: 10.1016/j.rmr.2013.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2013] [Accepted: 07/16/2013] [Indexed: 01/17/2023]
Affiliation(s)
- G Chanques
- Département d'anesthésie-réanimation, hôpital Saint-Éloi, CHRU de Montpellier, 80, avenue Augustin-Fliche, 34295 Montpellier cedex 5, France; Unité U1046, Institut national de la santé et de la recherche médicale (Inserm), université de Montpellier 1, université de Montpellier 2, 34295 Montpellier cedex 5, France.
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Reducing the pain of movement in intensive care. Br J Hosp Med (Lond) 2013. [DOI: 10.12968/hmed.2013.74.5.251b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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69
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Montpetit AJ, Sessler CN. Optimizing safe, comfortable ICU care through multi-professional quality improvement: just DO it. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:138. [PMID: 23659656 PMCID: PMC3672524 DOI: 10.1186/cc12601] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Translating research to the bedside can present significant challenges in the complex ICU environment. In this issue of Critical Care, de Jong and colleagues report on a quality improvement project (NURSE-DO) that led to a decrease in severe pain and serious adverse events during nursing care procedures in their ICU. In this commentary we describe three aspects of this quality improvement study that we think contributed to the overall success of the NURSE-DO project: the hospital environment and culture; multi-professional partnerships; and an evidence-based structured approach.
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