Implementation of a Pain, Agitation and Delirium Program in PICU: Improved comfort and decreased exposure to opioids and benzodiazepines
CCCF ePoster library. Lee L. 11/13/19; 283376; EP117
Ms. Laurie Lee
Ms. Laurie Lee
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Abstract
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ePoster
Topic: Quality Assurance & Improvement

Lee, Laurie A1,2; Nikitovic, Dejana3; Kraft, Timothy1; Kampman, Renee1; Bissett, Wendy1; Doughty, Paul1,3
1Pediatric Intensive Care Unit, Alberta Children's Hospital, Calgary, Canada; 2Faculty of Nursing, University of Calgary, Calgary, Canada;3Cumming's School of Medicine, Univeristy of Calgary, Calgary, Canada


Introduction:
Over the last 5 years delirium has been recognized and explored in Pediatric Intensive Care Units (PICU). 25-60% of patients admitted to the PICU experience delirium. Children suffering from delirium have increased PICU Length of Stay (LOS), hospital LOS, ventilator days, and mortality. Pediatric and adult studies have indicated an association with opioids and benzodiazepines in the development of delirium. The Society of Critical Care Medicine recognized the burden of ICU delirium and championed widespread implementation of an ABCDEF bundle to reduce delirium.

Methods:
This project was conducted at the Alberta Children's Hospital, in a 20-bed medical-surgical PICU within a tertiary care children's hospital. The program was implemented for all patients admitted to the PICU. Outcome data was analyzed for those admitted to the PICU for > 48 hours from November 1, 2015-August 31, 2018.

Program Design:
The ABCDEF Bundle was adapted to create our PICU Pain, Agitation and Delirium (PAD) Program and it was implemented in 3 phases: 1) Revision and implementation of pain and agitation guideline; q4h pain scoring, q4h sedation scoring, and q24h delirium scoring; 2) Implementation of nurse led early mobilization and respiratory therapist led extubation readiness testing; 3) Focus on non-pharmacological pain and agitation management.

Each phase was rolled out using Plan-Do-Study-Act (PDSA) cycles. We utilized key facilitators for sustained change including: Recruitment and empowerment of multi-disciplinary frontline; education of all disciplines using evidence and family/patient testimonials; improved workflow for frontline staff; regular presence on rounds of Champion MD/NP; audit/feedback of expected targets; celebration and advertisement of successes; leveraging of local, site and provincial support.

Objectives:
1) Consistently measure pain, sedation/agitation and delirium;
2) Decrease prevalence of severe pain
3) Decrease prevalence of delirium;
4) Decrease use of opioids and benzodiazepines

Statistical process control (SPC) U charts were used to evaluate the impact of our PICU PAD program on our objectives.

Results:
Implementation of the PICU PAD program was associated with the following changes

  • >80% compliance with q4h pain scoring, q4h sedation/agitation scoring, and q24h delirium scoring.
  • Reduction in the prevalence of severe pain from 21.9% to 12.32%.
  • Reduction in the prevalence of PICU delirium from 57% to 46%
  • Reduction in the median days of opioid exposure from 44% to 39% of all PICU days
  • No change in the median mcg/kg/days exposed to opioids
  • Reduction in the median days of benzodiazepine exposure from 53% to 25% of all PICU days
  • Increase in median mcg/kg/days exposed to benzodiazepines from 235 mcg/kg/days exposed to 375 mcg/kg/days exposed
  • Reduction in ventilator days from 66 to 40 days per month

 
Conclusion: This project highlights that through implementation of a multi-disciplinary Pain, Agitation and Delirium program, with a focus on non-pharmacological therapy is feasible. The phased implementation of this program was associated with improved comfort, while decreasing patient's total exposure to both opioids and benzodiazepines. Patients also experienced less delirium and spent fewer days ventilated. Through dedication of staff and thorough knowledge translation patient care can be dramatically improved.


Image Image Image

1. Bettencourt A, Mullen JE. Delirium in Children: Identification, Prevention, and Management. Crit Care Nurse. 2017;37(3):e9-e18. doi:10.4037/ccn2017692
2. Alvarez R V., Palmer C, Czaja AS, et al. Delirium is a Common and Early Finding in Patients in the Pediatric Cardiac Intensive Care Unit. J Pediatr. 2018;195:206-212. doi:10.1016/j.jpeds.2017.11.064
3. Elliott SR. ICU delirium: A survey into nursing and medical staff knowledge of current practices and perceived barriers towards ICU delirium in the intensive care unit. Intensive Crit Care Nurs. 2014;30(6):333-338. doi:10.1016/j.iccn.2014.06.004
4. Silver G, Kearney J, Traube C, Atkinson TM, Wyka KE, Walkup J. Pediatric delirium: Evaluating the gold standard. Palliat Support Care. 2013;13(3):513-516. doi:10.1017/S1478951514000212
5. Daoud A, Duff JP, Joffe AR. Diagnostic accuracy of delirium diagnosis in pediatric intensive care: A systematic review. Crit Care. 2014;18(5):1-10. doi:10.1186/s13054-014-0489-x
6. Smeets IAP, Tan EYL, Vossen HGM, et al. Prolonged stay at the paediatric intensive care unit associated with paediatric delirium. Eur Child Adolesc Psychiatry. 2010;19(4):389-393. doi:10.1007/s00787-009-0063-2
7. Harris J, Ramelet AS, van Dijk M, et al. Clinical recommendations for pain, sedation, withdrawal and delirium assessment in critically ill infants and children: an ESPNIC position statement for healthcare professionals. Intensive Care Med. 2016;42(6):972-986. doi:10.1007/s00134-016-4344-1
8. Smith HAB, Brink E, Fuchs DC, Ely EW, Pandharipande PP. Pediatric Delirium. Monitoring and Management in the Pediatric Intensive Care Unit. Pediatr Clin North Am. 2013;60(3):742-760. doi:10.1016/j.pcl.2013.02.010
9. Paterson RS, Kenardy JA, De Young AC, Dow BL, Long DA. Delirium in the Critically Ill Child: Assessment and Sequelae. Dev Neuropsychol. 2017;42(6). doi:10.1080/87565641.2017.1374961
10. Traube C, Silver G, Reeder RW, et al. Delirium in Critically Ill Children: An International Point Prevalence Study. Crit Care Med. 2017;45(4):584-590. doi:10.1097/CCM.0000000000002250
11. Norman S, Taha AA, Turner HN. Delirium in the Critically Ill Child. Clin Nurse Spec. 2017;31(5):276-284. doi:10.1097/NUR.0000000000000324
12. Silver G, Kearney J, Traube C, Hertzig M. Delirium screening anchored in child development: The Cornell Assessment for Pediatric Delirium. Palliat Support Care. 2015;13(4):1005-1011. doi:10.1017/S1478951514000947
13. Simone S, Edwards S, Lardieri A, et al. Implementation of an ICU Bundle: An Interprofessional Quality Improvement Project to Enhance Delirium Management and Monitor Delirium Prevalence in a Single PICU. Pediatr Crit Care Med. 2017;18(6):531-540. doi:10.1097/PCC.0000000000001127

ePoster
Topic: Quality Assurance & Improvement

Lee, Laurie A1,2; Nikitovic, Dejana3; Kraft, Timothy1; Kampman, Renee1; Bissett, Wendy1; Doughty, Paul1,3
1Pediatric Intensive Care Unit, Alberta Children's Hospital, Calgary, Canada; 2Faculty of Nursing, University of Calgary, Calgary, Canada;3Cumming's School of Medicine, Univeristy of Calgary, Calgary, Canada


Introduction:
Over the last 5 years delirium has been recognized and explored in Pediatric Intensive Care Units (PICU). 25-60% of patients admitted to the PICU experience delirium. Children suffering from delirium have increased PICU Length of Stay (LOS), hospital LOS, ventilator days, and mortality. Pediatric and adult studies have indicated an association with opioids and benzodiazepines in the development of delirium. The Society of Critical Care Medicine recognized the burden of ICU delirium and championed widespread implementation of an ABCDEF bundle to reduce delirium.

Methods:
This project was conducted at the Alberta Children's Hospital, in a 20-bed medical-surgical PICU within a tertiary care children's hospital. The program was implemented for all patients admitted to the PICU. Outcome data was analyzed for those admitted to the PICU for > 48 hours from November 1, 2015-August 31, 2018.

Program Design:
The ABCDEF Bundle was adapted to create our PICU Pain, Agitation and Delirium (PAD) Program and it was implemented in 3 phases: 1) Revision and implementation of pain and agitation guideline; q4h pain scoring, q4h sedation scoring, and q24h delirium scoring; 2) Implementation of nurse led early mobilization and respiratory therapist led extubation readiness testing; 3) Focus on non-pharmacological pain and agitation management.

Each phase was rolled out using Plan-Do-Study-Act (PDSA) cycles. We utilized key facilitators for sustained change including: Recruitment and empowerment of multi-disciplinary frontline; education of all disciplines using evidence and family/patient testimonials; improved workflow for frontline staff; regular presence on rounds of Champion MD/NP; audit/feedback of expected targets; celebration and advertisement of successes; leveraging of local, site and provincial support.

Objectives:
1) Consistently measure pain, sedation/agitation and delirium;
2) Decrease prevalence of severe pain
3) Decrease prevalence of delirium;
4) Decrease use of opioids and benzodiazepines

Statistical process control (SPC) U charts were used to evaluate the impact of our PICU PAD program on our objectives.

Results:
Implementation of the PICU PAD program was associated with the following changes

  • >80% compliance with q4h pain scoring, q4h sedation/agitation scoring, and q24h delirium scoring.
  • Reduction in the prevalence of severe pain from 21.9% to 12.32%.
  • Reduction in the prevalence of PICU delirium from 57% to 46%
  • Reduction in the median days of opioid exposure from 44% to 39% of all PICU days
  • No change in the median mcg/kg/days exposed to opioids
  • Reduction in the median days of benzodiazepine exposure from 53% to 25% of all PICU days
  • Increase in median mcg/kg/days exposed to benzodiazepines from 235 mcg/kg/days exposed to 375 mcg/kg/days exposed
  • Reduction in ventilator days from 66 to 40 days per month

 
Conclusion: This project highlights that through implementation of a multi-disciplinary Pain, Agitation and Delirium program, with a focus on non-pharmacological therapy is feasible. The phased implementation of this program was associated with improved comfort, while decreasing patient's total exposure to both opioids and benzodiazepines. Patients also experienced less delirium and spent fewer days ventilated. Through dedication of staff and thorough knowledge translation patient care can be dramatically improved.


Image Image Image

1. Bettencourt A, Mullen JE. Delirium in Children: Identification, Prevention, and Management. Crit Care Nurse. 2017;37(3):e9-e18. doi:10.4037/ccn2017692
2. Alvarez R V., Palmer C, Czaja AS, et al. Delirium is a Common and Early Finding in Patients in the Pediatric Cardiac Intensive Care Unit. J Pediatr. 2018;195:206-212. doi:10.1016/j.jpeds.2017.11.064
3. Elliott SR. ICU delirium: A survey into nursing and medical staff knowledge of current practices and perceived barriers towards ICU delirium in the intensive care unit. Intensive Crit Care Nurs. 2014;30(6):333-338. doi:10.1016/j.iccn.2014.06.004
4. Silver G, Kearney J, Traube C, Atkinson TM, Wyka KE, Walkup J. Pediatric delirium: Evaluating the gold standard. Palliat Support Care. 2013;13(3):513-516. doi:10.1017/S1478951514000212
5. Daoud A, Duff JP, Joffe AR. Diagnostic accuracy of delirium diagnosis in pediatric intensive care: A systematic review. Crit Care. 2014;18(5):1-10. doi:10.1186/s13054-014-0489-x
6. Smeets IAP, Tan EYL, Vossen HGM, et al. Prolonged stay at the paediatric intensive care unit associated with paediatric delirium. Eur Child Adolesc Psychiatry. 2010;19(4):389-393. doi:10.1007/s00787-009-0063-2
7. Harris J, Ramelet AS, van Dijk M, et al. Clinical recommendations for pain, sedation, withdrawal and delirium assessment in critically ill infants and children: an ESPNIC position statement for healthcare professionals. Intensive Care Med. 2016;42(6):972-986. doi:10.1007/s00134-016-4344-1
8. Smith HAB, Brink E, Fuchs DC, Ely EW, Pandharipande PP. Pediatric Delirium. Monitoring and Management in the Pediatric Intensive Care Unit. Pediatr Clin North Am. 2013;60(3):742-760. doi:10.1016/j.pcl.2013.02.010
9. Paterson RS, Kenardy JA, De Young AC, Dow BL, Long DA. Delirium in the Critically Ill Child: Assessment and Sequelae. Dev Neuropsychol. 2017;42(6). doi:10.1080/87565641.2017.1374961
10. Traube C, Silver G, Reeder RW, et al. Delirium in Critically Ill Children: An International Point Prevalence Study. Crit Care Med. 2017;45(4):584-590. doi:10.1097/CCM.0000000000002250
11. Norman S, Taha AA, Turner HN. Delirium in the Critically Ill Child. Clin Nurse Spec. 2017;31(5):276-284. doi:10.1097/NUR.0000000000000324
12. Silver G, Kearney J, Traube C, Hertzig M. Delirium screening anchored in child development: The Cornell Assessment for Pediatric Delirium. Palliat Support Care. 2015;13(4):1005-1011. doi:10.1017/S1478951514000947
13. Simone S, Edwards S, Lardieri A, et al. Implementation of an ICU Bundle: An Interprofessional Quality Improvement Project to Enhance Delirium Management and Monitor Delirium Prevalence in a Single PICU. Pediatr Crit Care Med. 2017;18(6):531-540. doi:10.1097/PCC.0000000000001127

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