Using the Model for Improvement to implement the Critical-Care Pain Observation Tool in an adult intensive care unit

Abstract

Managing pain is challenging in the intensive care unit (ICU) as often patients are unable to self-report due to the effects of sedation required for mechanical ventilation. Minimal sedative use and the utilisation of analgesia-first approaches are advocated as best practice to reduce unwanted effects of oversedation and poorly managed pain. Despite evidence-based recommendations, behavioural pain assessment tools are not readily implemented in many critical care units. A local telephone audit conducted in April 2017 found that only 30% of Scottish ICUs are using these validated pain instruments. The intensive care unit (ICU) at Raigmore Hospital, NHS Highland, initiated a quality improvement (QI) project using the Model for Improvement (MFI) to implement an analgesia-first approach utilising a validated and reliable behavioural pain assessment tool, namely the Critical-Care Pain Observation Tool (CPOT). Over a six-month period, the project deployed QI tools and techniques to test and implement the CPOT. The process measures related to (i) the nursing staff’s reliability to assess and document pain scores at least every four hours and (ii) to treat behavioural signs of pain or CPOT scores ≥ 3 with a rescue bolus of opioid analgesia. The findings from this project confirm that the observed trends in both process measures had reduced over time. Four hourly assessments of pain had increased to 89% and the treatment of CPOT scores ≥3 had increased to 100%.

The impact of the COVID-19 lockdown on orthopaedic emergency presentations in a remote and rural population

“…Tertiary services are available in the central belt of Scotland and Aberdeen which are a two- to three-hour drive from our hospital. 3 , 4…”

Use of PADIS Assessment Tools by Critical Care Nurses: An Integrative Review

“…Nurses use of the CAM-ICU improved organization of assessment (Scott et al, 2013) and improved patient outcomes (Oosterhouse et al, 2016). Use of the CAM-ICU also facilitated recognition of hypoactive delirium (Jung et al, 2013;Schaef, 2019) and distinguished between other causes of restlessness (Zamoscik (Bourbonnais et al, 2016); positive correlation between perceived importance and use (Hamdan, 2019) (−) physiological parameters interpreted as pain episode (Alikiaie et al, 2019;Gerber et al, 2015); prefers own clinical judgement (Deldar et al, 2018;Mascarenhas et al, 2018); does not believe result; belief that tool is not necessary if sedated/given analgesics; belief that unconscious patients feel no pain; unfamiliar with tool (Deldar et al, 2018); consider nurses' opinion as gold standard (Van Der Woude et al, 2016); used tool more in patients able to report than unable to report (Hamdan, 2019); knowledge of behaviors indicating pain was negatively correlated with perceived adequacy of departmental pain treatment (r = −0.19, p < 0.05) (Asman et al, 2019) Agitation (+) awareness of paradigm shift to "awake and comfortable" (Egerod et al, 2013); tool use balanced with other assessments (Hetland et al, 2018) Delirium (+) tool use increased awareness of delirium (Jung et al, 2013); tool use supplemented other assessments (LeBlanc et al, 2018); patient-centered care; perception of delirium as a problem (Özsaban & Acaroglu, 2016); retained knowledge after education intervention (Smith et al, 2017); understood how to use (Swan, 2014); belief that delirium is important to assess (Powell et al, 2019) (−) mechanically ventilated patients (Andrews et al, 2015;Özsaban & Acaroglu, 2016;Rowley-Conwy, 2017;Scott et al, 2013); prefers own clinical judgement (Christensen, 2014;Steinseth et al, 2018;Zamoscik et al, 2017); question accuracy ...…”

“…Pain (+) increased autonomy and accountability (Mascarenhas et al, 2018) Agitation (+) >90% used tool without protocol in place (Egerod et al, 2013); 68% agreed tool use increased autonomy and enhanced role (Sneyers et al, 2014) (−) more MDs than RNs agreed that tool use increased RN autonomy and enhanced roles (Sneyers et al, 2014) Delirium (+) ownership/engagement/empowerment; meaning and value to work (DiLibero et al, 2016) (−) considered to be "tick-box"/ "cookie-cutter" nursing (Christensen, 2014;LeBlanc et al, 2018); limits autonomy (LeBlanc et al, 2018); incompatible roles of caregiver vs. interrogator; threatens professional integrity (Oxenbøll-Collet et al, 2018); "unable to assess" option as work-around to opt out of documentation (Spiegelberg et al, 2020) Pain, agitation/ sedation, delirium (−) own experience and judgement are being challenged (Wøien & Bjørk, 2013) Note. Data analysis was guided by Consolidated Framework for Implementation Research (CFIR; Damschroder et al, 2009).…”

Ignorance may be Bliss (for Intensivists), but not for ICU Patients!

“…There are lessons that can be learnt from quality improvement programs specifically focused on use of pain scales in the ICU. 9 An outstanding example is from the Raigmore Hospital initiative. 9 An analgesia first approach—model for improvement utilizing the CPOT was enforced.…”

“…9 An outstanding example is from the Raigmore Hospital initiative. 9 An analgesia first approach—model for improvement utilizing the CPOT was enforced. Over a 6-month period, the project using quality improvement tools and techniques emphasized on implementation of the CPOT.…”