Pain, agitation and delirium assessment and management in a community medical-surgical ICU: results from a prospective observational study and nurse survey

Abstract

BackgroundDelirium is a common manifestation in the intensive care unit (ICU) that is associated with increased mortality and morbidity. Guidelines suggested appropriate management of pain, agitation and delirium (PAD) is crucial in improving patient outcomes. However, the practice of PAD assessment and management in community hospitals is unclear and the mechanisms contributing to the potential care gap are unknown.ObjectivesThis quality improvement initiative aimed to review the practice of PAD assessment and management in a community medical-surgical ICU (MSICU) and to explore the community MSICU nurses’ perceived comfort and satisfaction with PAD management in order to understand the mechanisms of the observed care gap and to inform subsequent quality improvement interventions.MethodsWe prospectively collected basic demographic data, clinical information and daily data on PAD process measures including PAD assessment and target Richmond Agitation-Sedation Scale (RASS) score ordered by intensivists on all patients admitted to a community MSICU for >24 hours over a 20-week period. All ICU nurses in the same community MSICU were invited to participate in an anonymous survey.ResultsWe collected data on a total of 1101 patient-days (PD). 653 PD (59%), 861 PD (78%) and 439 PD (39%) had PAD assessment performed, respectively. Target RASS was ordered by the intensivists on 515 PD (47%). Our nurse survey revealed that 88%, 85% and 41% of nurses were comfortable with PAD assessment, respectively.ConclusionsDelirium assessment was not routinely performed. This is partly explained by the discomfort nurses felt towards conducting delirium assessment. Our results suggested that improvement in nurse comfort with delirium assessment and management is needed in the community MSICU setting.

Impact of a nurse engagement intervention on pain, agitation and delirium assessment in a community intensive care unit

“…The postintervention improvements in screening rates may have been the result of increased comfort with PAD assessment, which was identified as a care gap in an earlier part of this study 24. Other potential contributors include increased awareness of the importance of evaluating for PAD and clarification of misconceptions surrounding screening tools, both of which have been identified as barriers to optimal PAD assessment 26.…”

“…Information gathered from the nurse survey and focus groups suggested that the largest care gap existed in assessing and treating delirium, and that communication about PAD is lacking among members of the healthcare team 24 25. These findings led to the creation of nurse education sessions on PAD assessment, treatment and prevention, with a focus on delirium.…”

“…Previous studies have identified significant knowledge gaps when it comes to PAD assessment and treatment 24 26 28. Educational interventions have an important role in closing these gaps and are recommended as a strategy to facilitate PAD guideline implementation in the ICU 1 19.…”

The influence of a serious game’s narrative on students’ attitudes and learning experiences regarding delirium: an interview study

“…Low detection rates of delirium are often related to low delirium awareness, inadequate knowledge and education, lack of time, feeling uncomfortable with delirium assessment, and missing co-operation between professions. However, if the presence of delirium and/or increased risks are detected, such barrierstogether with negative attitudes towards deliriumare also related to suboptimal delirium management [2,14,[17][18][19].…”

Fostering community hospital research

“…2,9,11 For example, local Ontario quality improvement data showed improved nurse engagement and guideline adherence fol lowing a research project targeting pain, agitation and delirium con ducted in an intensive care unit (ICU) of a community hospital. 12 Enrolling patients from community hospitals into multicentre trials can also directly benefit studies. Patients in community hospitals may represent a different crosssection of society, thereby improving generalizability of study results.…”