Procedural Pain in the Adult Neurological Intensive Care Unit: A Retrospective Study Examining Arterial Line Insertion

BACKGROUND

This was a retrospective chart review of procedural pain assessments and interventions during arterial catheter insertion in an adult neurological intensive care unit where patients with impaired consciousness are common. Overall, pain assessment was well documented (100%) by Registered Nurses, but not specific to arterial line insertion. Nurse practitioners commonly placed arterial lines and used local analgesia in over 75% of the documented procedures.

AIMS

The purpose of this study was to examine healthcare providers' pain-related practices documented during arterial catheter insertion, one of the most painful procedures in a neurological intensive care unit. Secondary purposes were determining whether patient characteristics, procedure-related factors, or provider licensure were associated with pain assessment or procedural pain interventions.

DESIGN

A retrospective records review design was used.

METHODS

120 electronic patient medical records were reviewed during a one-year period.

RESULTS

100 charts met inclusion criteria. Nurses assessed all pain within 4 hours following the procedure in all charts but procedure-specific pain assessments were documented in 4% of charts. Pain-related interventions for arterial line insertion were local analgesic (76% of charts) and other procedure-specific interventions (10%). Significant associations occurred between procedure specific pain assessments and decreased number of insertion attempts (p = .006) and between pain interventions and number of insertion attempts (p = .003). No provider documented procedural pain assessment regarding arterial line insertion. Associations between patient characteristics and pain interventions were significant for patient ethnicity (F = 8.967, p = .007).

CONCLUSIONS

Overall pain assessment was documented (100%) but not specific to arterial line insertion. Although arterial line insertion can be extremely painful, patients were rarely assessed for such pain by any clinician; 14% did not receive any preprocedural analgesia.

CLINICAL IMPLICATIONS

The lack of procedural pain assessment in this vulnerable population indicates a need for increased pain management education for clinicians and further investigations to determine whether sufficient analgesia is provided to reduce procedural pain during arterial line insertion.

More than just a simple swish and spit: implementation of oral care best practice in clinical neurosciences

Suboptimal oral care is well documented in the literature and is linked to increased nosocomial pneumonia rates and prolonged hospitalization, negatively affecting patients' quality of life (Terezakis et al. 2011). A standardized approach to oral care can change these adverse outcomes. This project used best practice guidelines and evidence in the literature to guide the development of oral care best practice within an acute care inpatient unit. Based on the work of the interprofessional Clinical Neurological Sciences (CNS) Continuous Quality Improvement (CQI) Council at London Health Sciences Centre-University Hospital (LHSC-UH), an oral care policy and bedside assessment tool were implemented in line with Stroke Best Practice Recommendations (Heart and Stroke Foundation of Canada 2010). A validated, reliable and feasible oral health assessment tool (OHAT) was selected for implementation, and is now completed on every patient within 24 hours of admission to the CNS inpatient unit. Favourable outcomes to date include improved accessibility of oral health supplies, including regular and suction toothbrushes, toothpaste and bite blocks. Post-implementation audits indicate increased frequency and quality of oral care. This review provides a synopsis of how oral care best practice was implemented in an acute care neurology/neurosurgery setting.