Analgosedation: Improving Patient Outcomes in ICU Sedation and Pain Management

Sedation Experiences of Pediatric Intensive Care Nurses: Exploring PICU Nurse Perspectives on Sedative Management and Communication

Objective: This study's purpose is to better understand pediatric intensive care nursing perspectives on sedative management as a precursor to improving aspects of sedation assessment, titration, and communication. Methods/Design: We queried nurses in the pediatric intensive care unit at a 40+ bed quaternary care using an electronic survey about their experiences with sedation management. Data was collected using REDCap and statistical analyses were performed to assess for differences between experience levels in areas. Results: Seventy nurses responded with 42% response rate. More than 95% were comfortable calculating sedation and delirium scores. Those with less than 5 years' experience were significantly more likely to consider sedation scores helpful (P = .04) and also significant more likely to agree that delirium scores are used effectively (P = .01). Eighty-eight percent of respondents were comfortable raising concerns about sedation to the multidisciplinary team, but those with less than 5 years' experience were significantly less likely to express concerns to attending (P = .001). Conclusion: Newer nurses are more inclined to support use of standardized scoring systems for sedation and delirium, but less comfortable approaching attending clinicians with their concerns. Intensive care teams should pay careful attention to team dynamics, particularly as they apply to sedative management and work to improve communication, collaboration, and educational interventions to improve patient care. Further work understanding nursing perspectives and further attempts to improve interprofessional communication seems a wise investment and could obviate barriers that may exist.

Improving Outcomes in Mechanically Ventilated Adult ICU Patients Following Implementation of the ICU Liberation (ABCDEF) Bundle Across a Large Healthcare System

OBJECTIVES

To measure how the ICU Liberation Bundle (aka ABCDEF Bundle or the Bundle) affected clinical outcomes in mechanically ventilated (MV) adult ICU patients, as well as bundle sustainability and spread across a healthcare system.

DESIGN

We conducted a multicenter, prospective, cohort observational study to measure bundle performance versus patient outcomes and sustainability in 11 adult ICUs at six community hospitals. We then prospectively measured bundle spread and performance across the other 28 hospitals of the healthcare system.

SETTING

A large community-based healthcare system.

PATIENTS

In 11 study ICUs, we enrolled 1,914 MV patients (baseline n = 925, bundle performance/outcomes n = 989), 3,019 non-MV patients (baseline n = 1,323, bundle performance/outcomes n = 1,696), and 2,332 MV patients (bundle sustainability). We enrolled 9,717 MV ICU patients in the other 28 hospitals to assess bundle spread.

INTERVENTIONS

We used evidence-based strategies to implement the bundle in all 34 hospitals.

MEASUREMENTS AND MAIN RESULTS

We compared outcomes for the 12-month baseline and bundle performance periods. Bundle implementation reduced ICU length of stay (LOS) by 0.5 days (p = 0.02), MV duration by 0.6 days (p = 0.01), and ICU LOS greater than or equal to 7 days by 18.1% (p < 0.01). Performance period bundle compliance was compared with the preceding 3-month baseline compliance period. Compliance with pain management and spontaneous awakening trial (SAT) and spontaneous breathing trial (SBT) remained high, and reintubation rates remained low. Sedation assessments increased (p < 0.01) and benzodiazepine sedation use decreased (p < 0.01). Delirium assessments increased (p = 0.02) and delirium prevalence decreased (p = 0.02). Patient mobilization and ICU family engagement did not significantly improve. Bundle element sustainability varied. SAT/SBT compliance dropped by nearly half, benzodiazepine use remained low, sedation and delirium monitoring and management remained high, and patient mobility and family engagement remained low. Bundle compliance in ICUs across the healthcare system exceeded that of study ICUs.

CONCLUSIONS

The ICU Liberation Bundle improves outcomes in MV adult ICU patients. Evidence-based implementation strategies improve bundle performance, spread, and sustainability across large healthcare systems.

Intensive care nurses' experiences using volatile anaesthetics in the intensive care unit: An exploratory study

OBJECTIVE

To explore the experiences intensive care nurses have with volatile anaesthetics in the intensive care unit.

RESEARCH METHODOLOGY AND DESIGN

A qualitative exploratory and descriptive design was used. Data were collected in 2019 from individual interviews with nine intensive care nurses, who were recruited using purposive sampling. Data were analysed using systematic text condensation.

SETTING

The study was undertaken in two general intensive care units from different university hospitals in Norway where volatile anaesthetics were utilised.

FINDINGS

Three categories emerged from the data analysis: experiencing the benefits of volatile anaesthetics; coping with unfamiliarity in handling volatile anaesthetics; and meeting challenges related to volatile anaesthetics in practice.

CONCLUSION

The intensive care nurses had positive experiences related to administering volatile anaesthetics in the intensive care unit and responded positively to the prospect of using it more often. Because volatile anaesthetics were rarely used in their units, the participants felt uncertain regarding its use due to unfamiliarity. Collegial support and guidelines were perceived as pivotal in helping them cope with this uncertainty. The participants also experienced several challenges in using volatile anaesthetics in the intensive care unit, with ambient pollution being regarded as the main challenge.

Predictors of physical restraint use on critical care units: An observational structural equation modeling approach

BACKGROUND

Modifiable unit characteristics, including nurse work environment, education, certification, and staffing have been shown to impact patient safety. Physical restraints are an important patient safety issue, however the relationships between these modifiable unit characteristics and physical restraint use on critical care units has not been explored.

OBJECTIVES

Our objective was to determine the role of nursing work environment, nurse education and certification, and nurse staffing on physical restraint use.

DESIGN

The study was a secondary analysis of 2017-2018 unit-level restraint rates from the National Database of Nursing Quality Indicators linked to Registered Nurse survey and hospital characteristics data.

METHODS

Work environment was examined at the unit-level using total Practice Environment Scale of the Nursing Work Index and subscale scores. Unit-level nurse expertise included the percent of nurses with at least a Bachelor of Science in Nursing degree and percent with certification. Nurse staffing was the unit-level Registered Nurse hours per patient day and skill mix. Analyses included descriptive statistics, bivariate correlations, and Structural Equation Modeling. We used a first order model to estimate predicted restraint use from the five subscales of the Practice Environment Scale of the Nursing Work Index. A higher order model predicted restraint use from a total work environment factor score.

RESULTS

The sample included 408 critical care units from 226 hospitals. Mean restraint rate was 15% (SD 12, range 0-53%). In the first-order model, the Collegial Nurse-Physician Relations subscale had a positive relationship with restraint use (β = 0.167, 95% confidence interval 0.010-0.333). In the higher order model, the total work environment score had a negative relationship with restraint use (β = -0.088, 95% confidence -0.178- -0.014). Registered Nurse hours per patient day had a negative relationship to restraint use in both the first order (β = -0.114, 95% confidence interval -0.222--0.025) and higher order models (β = -0.117, 95% confidence interval -0.223- -0.012).

CONCLUSION

We found that better nurse-physician relationships were associated with higher restraint use. This finding is supported by previous literature and may reflect physician trust in nursing judgement when using restraints. However, a better work environment overall was associated with lower restraint rates. Further, Registered Nurse hours per patient day, but not skill mix, was associated with lower restraint rates. We conclude that improving the overall nurse work environment and nurse staffing, as well as using interprofessional interventions, may be successful in decreasing restraint use on critical care units.

Nurses' use of non-pharmacological pain management methods in intensive care units: A descriptive cross-sectional study

BACKGROUND

Pain is a common and unpleasant feeling among patients in intensive care units. Therefore, the use of proper pain management methods, such as non-pharmacological interventions, is a priority in intensive care units.

OBJECTIVE

This study aimed to ascertain the extent of the use of non-pharmacological pain management methods by intensive care unit nurses in Iran and to identify the obstacles that hindered the use of these methods.

MATERIAL AND METHODS

This study used a descriptive cross-sectional design which involved a convenience sample of 224 nurses who worked in 16 intensive care units across northern Iran. Data were collected using the non-pharmacological pain management questionnaire and a researcher-developed checklist of the obstacles that hindered the use of non-pharmacological pain management methods.

RESULTS

A moderate number of ICU nurses used non-pharmacological pain management methods (55.8 %). The most common method used by nurses was repositioning (M = 2.72), while methods such as acupuncture and reflexology were used less frequently. Furthermore, the most common obstacles to the use of non-pharmacological pain management methods were nurses' fatigue (M = 2.92) and multiple responsibilities (M = 2.91). Demographic variables such as age, gender, educational level, and work experience were not significantly associated with the use of non-pharmacological pain management methods.

CONCLUSIONS

Due to factors such as fatigue, multiple responsibilities, a heavy workload, and an insufficient number of nurses per shift, the rate of utilization of non-pharmacological pain management methods among intensive care unit nurses in Iran was low. Furthermore, most of the participants in this study had not attended courses on non-pharmacological pain management.

Recall of pain and discomfort during oral procedures experienced by intubated critically ill patients in the intensive care unit: A qualitative elicitation study

Background: Intubated and mechanically ventilated patients in the intensive care unit (ICU) may experience pain during routine oral procedures such as oral suctioning and tooth brushing. Despite the importance of pain prevention and management, little is known about patients’ experiences of procedural oral pain.

Aims: The aim of this study was to explore patients’ recollections and recommendations for pain and discomfort during routine oral procedures.

Methods: A qualitative descriptive design was used. Adult patients were recruited from a mixed medical–surgical–trauma ICU in an academic hospital in Toronto, Canada. Participants were interviewed using object elicitation methods within 7 days of discharge from the ICU. Data were analyzed using directed content analysis methods.

Results: We recruited 33 participants who were primarily male (23, 70%), with an average age of 54 (SD = 18) years, admitted with a medical (13, 39%), trauma (11, 33%), or surgical (9, 27%) diagnosis and dentate (27, 82%). Most participants described oral procedures as painful, discomforting, and emotionally distressing. Identified sources of pain included dry, inflamed oral tissues and procedural technique. Procedural pain behaviors were perceived to be frequently misinterpreted by clinicians as agitation, with consequences including physical restraint and unrelieved suffering. Participants advocated for greater frequency of oral care to prevent oral health deterioration, anticipatory procedural guidance, and structured pain assessment to mitigate the dehumanizing experience of unmanaged pain.

Conclusions: Patients described routine oral care procedures as painful and recalled suboptimal management of such pain. Procedural oral pain is an important target for practice improvement.

The effect of using Richmond agitation and sedation scale on hospital stay, ventilator dependence, and mortality rate in ICU inpatients: a randomised clinical trial

Background

Managing the amount of use of sedatives due to their high side effects in the intensive care unit is essential. Sedation-agitation protocols may play an important role in this regard. However, they have not been practically applied in Iran.

Aims

This study aimed to evaluate the effect of using the Richmond agitation and sedation scale on hospital stay duration and dependency rate on the intensive care unit ventilator system in Ahwaz City, Iran, in 2016-2017.

Methods

This randomised clinical trial was conducted on 74 patients. The subjects were selected by a stratified sampling method and divided into the experimental (n = 32) and control (n = 32) groups. Sedation and agitation levels were managed by the Richmond agitation and sedation scale as soon as the samples were anxious and agitated, and every 6 hours in the intervention group. However, the control group received routine care. The data obtained were analysed by the Statistical Package for the Social Sciences (SPSS).

Results

There was no significant difference between the two groups in terms of demographic variables, such as age, gender, admission diagnosis and Glasgow coma scale scores on admission. However, they differed in terms of hospital stay duration and ventilator connection (P < 0.001), Glasgow coma scale score at the separation time from the device (P < 0.001), Glasgow coma scale score at the discharge time from the intensive care unit (P < 0.02) and intensive care unit death rate (P < 0.001). In all cases mentioned previously, the intervention group's condition was better.

Conclusions

Based on the results of this study, as well as the approval of validation and reliability of the Richmond agitation and sedation scale in different studies, this protocol can be very effective in optimising the use of sedatives in the intensive care unit.

Diurnal Variation and Nursing Perspectives in Analgesic and Sedation Medication Administration to Mechanically Ventilated Children in a Single Pediatric ICU

The primary objective of this study was to determine whether there was diurnal variation in the amount of analgesic and sedation medication administered to mechanically ventilated children in a single pediatric intensive care unit (PICU). The secondary objective was to evaluate nursing attitudes and practices regarding administration of these medications. This was a prospective, longitudinal cohort study of mechanically ventilated patients admitted to a single PICU. There were 46 mechanical ventilation courses included (305 paired day-night shifts). There was no significant diurnal variation found in the amount of analgesics and sedatives administered to mechanically ventilated patients. However, the reasons for administration differed between day and night shifts.

CE: Managing Pain in Critically Ill Adults: A Holistic Approach

Nurses caring for critically ill adults are challenged to balance patient comfort with the risk of complications associated with analgesic therapy. Evidence gathered since 2013, when the Society of Critical Care Medicine (SCCM) published the Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit, known as the PAD guidelines, gave rise to the SCCM 2018 publication of the Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU, known as the PADIS guidelines. This article discusses how the PADIS guidelines go beyond the PAD guidelines, providing specific guidance related to risk factors for pain, the assessment and management of pain in critical illness, and the ways in which the experience of pain in critical illness is intertwined with that of agitation, delirium, immobility, and sleep disruption. Tables summarize the key points in the PADIS guidelines, clarify the distinctions between PADIS and PAD, and describe the implications for nurses.

A national survey on routines regarding sedation in Swedish intensive care units

Background: Previous studies concerning sedation in Swedish intensive care units (ICU) have shown variability in drug choices and strategies. Currently, there are no national guidelines on this topic. As an update to a Nordic survey from 2004, and as a follow-up to a recently introduced quality indicator from the Swedish Intensive Care Registry, we performed a national survey. Methods: A digital survey was sent to the ICUs in Sweden, asking for sedation routines regarding hypnosedatives, analgosedatives, protocols, sedation scales, etc. Results: Fifty out of 80 ICUs responded to the survey. All units used sedation scales, and 88% used the RASS scale; 80% used written guidelines for sedation. Propofol and dexmedetomidine were the preferred short-term hypnosedatives. Propofol, dexmedetomidine, and midazolam were preferred for long-term hypnosedation. Remifentanil, morphine, and fentanyl were the most frequently used agents for analgosedation. Conclusions: All ICUs used a sedation scale, an increase compared with previous studies. Concerning the choice of hypno- and analgosedatives, the use of dexmedetomidine, clonidine, and remifentanil has increased, and the use of benzodiazepines has decreased since the Nordic survey in 2004.

Psychometric Properties of the Behavioral Pain Scale in Traumatic Brain Injury

BACKGROUND

Pain assessment of patients with traumatic brain injury is a challenge because they are unable to self-report their pain experience.

AIMS

To investigate the psychometric properties of validity, reliability, and responsiveness of the Brazilian version of the Behavioral Pain Scale (BPS-Br) in patients with traumatic brain injury.

METHODS

This was an observational, cross-sectional, repeated-measure and analytical study. This study was developed at the medical and surgical ICUs in a high-complexity public hospital at Aracaju, Sergipe, Brazil. Thirty-seven adult patients with moderate or severe TBI were included. This study was completed with 444 independent observations, a pairwise comparison, and was performed simultaneously before, during, and after eye cleaning and endotracheal suctioning of 37 adult patients with moderate to severe traumatic brain injury.

RESULTS

The BPS-Br had good internal consistency (.7 ≤ α ≤ .9), good discriminant validity (p < .001), moderate to excellent reliability based on inter-rater agreement (intraclass correlation coefficient = 0.66-1.00; κ = 0.5-1.0), and high responsiveness (0.7-1.7). The upper limbs subscale had the highest score during the nociceptive procedure (1.8 ± 0.9). Deep sedation affected the increase of grading during painful procedures (p < .001).

CONCLUSIONS

Our results suggest the BPS-Br is a useful tool for clinical practice to evaluate the pain experienced by patients with traumatic brain injury. Further studies of different samples are needed to evaluate the benefits of systematic pain assessment of critically ill patients.

"Do not do" recommendations of the working groups of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) for the management of critically ill patients

The project "Commitment to Quality of Scientific Societies", promoted since 2013 by the Spanish Ministry of Health, seeks to reduce unnecessary health interventions that have not proven effective, have little or doubtful effectiveness, or are not cost-effective. The objective is to establish the "do not do" recommendations for the management of critically ill patients. A panel of experts from the 13 working groups (WGs) of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) was selected and nominated by virtue of clinical expertise and/or scientific experience to carry out the recommendations. Available scientific literature in the management of adult critically ill patients from 2000 to 2017 was extracted. The clinical evidence was discussed and summarized by the experts in the course of consensus finding of each WG, and was finally approved by the WGs after an extensive internal review process carried out during the first semester of 2017. A total of 65 recommendations were developed, of which 5 corresponded to each of the 13 WGs. These recommendations are based on the opinion of experts and scientific knowledge, and aim to reduce those treatments or procedures that do not add value to the care process; avoid the exposure of critical patients to potential risks; and improve the adequacy of health resources.