Impact of a Multifaceted Nurse Engagement Intervention on Pain, Agitation, and Delirium Assessment in a Community Intensive Care Unit
CCCF ePoster library. Tan C. Nov 9, 2018; 233376; 114 Disclosure(s): This work was supported by the Ontario Nurses’ Association and the McMaster University, Department of Medicine, E. J. Moran Campbell Internal Research Career Award 2015-2018 (Jennifer LY Tsang).
Dr. Carolyn Tan
Dr. Carolyn Tan
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Delirium affects up to 80% of patients in the intensive care unit (ICU) and is associated with multiple adverse outcomes1. In 2013, ICU pain, agitation, and delirium (PAD) guidelines were published. Despite the well-established advantages of implementing PAD guidelines, adoption and adherence remain suboptimal2. This is especially true in community hospitals, where there are lower rates of monitoring and less frequent use of validated screening tools3,4. Educational interventions have been shown to address barriers to guideline implementation5. However, the impact of multifaceted nurse engagement interventions in community ICUs is unknown.



The purpose of this prospective interventional study was to evaluate the effect of a Multifaceted Nurse Engagement Intervention on PAD assessment in a community ICU.



All patients admitted to our community ICU for over 24 hours were included. A 20-week baseline audit was performed, followed by implementation of the intervention over 44 weeks, and a 20-week post-intervention audit. The Multifaceted Nurse Engagement Intervention consisted of a survey, focus groups, and education sessions. The survey assessed nurses’ perceived comfort, knowledge, and satisfaction surrounding PAD assessment and treatment. These findings informed the development of focus groups which aimed to better understand barriers to optimal PAD assessment and treatment from the nurses’ perspective. The final phase, the interactive nurse education sessions, were designed based on findings from the survey and focus groups.


To evaluate changes in daily PAD assessment, the following process measures were examined as the outcomes of this study: rate of pain assessment using the Numeric Pain Rating Scale (NRS), rate of agitation assessment using the Richmond Agitation-Sedation Scale (RASS), rate of delirium assessment using the Confusion Assessment Method for the ICU (CAM-ICU), and rate of target RASS scores ordered by intensivists. These screening tools were recommended in the 2013 PAD guidelines. Self-extubation and physical restraint use were examined as balancing measures as they are known complications of inappropriate levels of sedation.



There were significant improvements in the proportion of patients with at least one assessment per day of pain (67.5±11.9% v. 59.3±12.2%, p=0.04), agitation (93.1±4.3% v. 78.7±8.2%, p < 0.001), and delirium (54.2±10.2% v. 39.4±11.6%, p < 0.001) (Figure 1, 2), as well as number of patients with target RASS ordered (63.1±15.8% v. 46.8±15.6%, p=0.002) (Figure 3). There was a significant decrease in rate of physical restraint use (10.0±7.2% v. 30.9±15.9%, p < 0.001) and no change in rate of self-extubation (0.9±1.9% v. 2.5±5.2%, p=0.2) (Figure 3).



The implementation of a Multifaceted Nurse Engagement Intervention has the potential to improve rates of PAD assessment in community ICUs. Screening rates in our ICU remain suboptimal despite these improvements. We plan to implement multidisciplinary interventions targeting physicians, nurses, and family members to close the observed care gap.

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