疼痛、躁动与谵妄指南：跨专业视角下的证据转化

Pain, Agitation, and Delirium Guidelines: Interprofessional Perspectives to Translate the Evidence.

作者信息

Jablonski Juliane, Gray Jaime, Miano Todd, Redline Gretchen, Teufel Heather, Collins Tara, Pascual-Lopez Jose, Sylvia Martha, Martin Niels D

机构信息

Juliane Jablonski, DNP, RN, CCRN, CCNS, is a clinical nurse specialist in surgical critical care at the Hospital of the University of Pennsylvania for the past 7 years now in the role of a Critical Care Registered Nurse Systems Strategist for Penn Medicine, Philadelphia, Pennsylvania. Jaime Gray, PharmD, BCPS, is a clinical pharmacy specialist in surgical critical care at the Hospital of the University of Pennsylvania, Philadelphia. Todd Miano, PharmD, MSCE, is a clinical pharmacy specialist in surgical critical care at the Hospital of the University of Pennsylvania and postdoctoral fellow of Biostatistics and Epidemiology at the University of Pennsylvania, Philadelphia. Gretchen Redline, PharmD, BCPS, is a clinical pharmacy specialist in surgical critical care at the Hospital of the University of Pennsylvania, Philadelphia. Heather Teufel, PharmD, BCPS, is a clinical pharmacist in the emergency department at Chester County Hospital, Chester County, Pennsylvania. Tara Collins, ACNP, RN, is an acute care nurse practitioner in surgical critical care and director of Advanced Practice at Penn Presbyterian Medical Center, Philadelphia, Pennsylvania. Jose Pascual-Lopez, MD, PhD, FACS, is a trauma surgeon and critical care intensivist at the University of Pennsylvania and co -medical director for Surgical Critical Care at the Hospital of the University of Pennsylvania, Philadelphia. Martha Sylvia, PhD, MBA, RN, is a director of Population Health Analytics at Medical University of South Carolina, associate professor at the Medical University of South Carolina and College of Nursing, and adjunct faculty appointment at Johns Hopkins University School of Nursing, Baltimore, Maryland. Niels D. Martin, MD, FACS, FCCM, is a section chief of surgical critical care, program director for the Surgical Critical Care Fellowship Training Program, and assistant professor in the Department of Surgery at the University of Pennsylvania Perelman School of Medicine, Philadelphia.

出版信息

Dimens Crit Care Nurs. 2017 May/Jun;36(3):164-173. doi: 10.1097/DCC.0000000000000239.

DOI:10.1097/DCC.0000000000000239

PMID:28375992

Abstract

BACKGROUND

Societal guidelines exist for the management of pain, agitation, and delirium (PAD) in critically ill patients. This contemporary practice aims for a more awake and interactive patient. Institutions are challenged to translate the interrelated multivariable concepts of PAD into daily clinical practice and to demonstrate improvement in quality outcomes. An interdisciplinary goal-directed approach shows outcomes in high-acuity surgical critical care during the early stages of implementation.

METHODS

This study was a prospective preintervention and postintervention design. A formal PAD clinical practice guideline targeting standardized assessment and "light" levels of sedation was instituted. All mechanically ventilated patients admitted to a 24-bed surgical intensive care unit (ICU) at an academic medical center during a 6-month period were included (3 months before and 3 months after implementation). Sedation and agitation were measured using the Richmond Agitation Sedation Scale (RASS), pain measured using a Behavioral or Numeric Pain Scale (NPS/BPS), and delirium using the Confusion Assessment Method for the Intensive Care Unit. Total ventilator days with exposure to continuous opioid or sedative infusions and total ICU days where the patient received a physical activity session exercising out of bed were recorded.

RESULTS

There were 106 patients (54 at preintervention and 52 at postintervention). Mean percentage of RASS scores between 0 to -1 increased from 38% to 50% postintervention (P < .02). Mean percentage of NPS/BPS scores within the goal range (<5 for BPS and <3 for NPS) remained stable, 86% to 83% (P = .16). There was a decrease in use of continuous narcotic infusions for mechanically ventilated patients. This was reported as mean percentage of total ventilator days with a continuous opioid infusing: 65% before implementation versus 47% after implementation (P < .01). Mean percentage of ICU days with physical activity sessions increased from 24% to 41% (P < .001). Overall mean ventilator-free days and ICU length of stay were 5.4 to 4.5 days (P = .29) and 11.75 to 9.5 days (P = .20), respectively.

CONCLUSION

Measureable patient outcomes are achievable in the early stages of PAD guideline initiatives and can inform future systems-level organizational change. Pain, agitation, and delirium assessment tools form the foundation for clinical implementation and evaluation. High-acuity surgical critical care patients can achieve more time at goal RASS, decreased ventilator days, and less exposure to continuous opioid infusions, all while maintaining stable analgesia.

摘要

背景

针对危重症患者的疼痛、躁动和谵妄（PAD）管理存在社会指南。这种现代实践旨在使患者更加清醒和具有互动性。各机构面临着将PAD相互关联的多变量概念转化为日常临床实践并证明质量结果有所改善的挑战。一种跨学科的目标导向方法在实施早期阶段的高 acuity 外科重症监护中显示出了效果。

方法

本研究采用前瞻性干预前和干预后设计。制定了一项针对标准化评估和“轻度”镇静水平的正式 PAD 临床实践指南。纳入了在一个学术医疗中心的 24 张床位的外科重症监护病房（ICU）在 6 个月期间收治的所有机械通气患者（实施前 3 个月和实施后 3 个月）。使用 Richmond 躁动镇静量表（RASS）测量镇静和躁动，使用行为或数字疼痛量表（NPS/BPS）测量疼痛，使用重症监护病房谵妄评估方法测量谵妄。记录接受持续阿片类药物或镇静剂输注的总通气天数以及患者在床上进行身体活动的总 ICU 天数。

结果

共有 106 例患者（干预前 54 例，干预后 52 例）。干预后 RASS 评分在 0 至 -1 之间的平均百分比从 38% 增加到 50%（P <.02）。NPS/BPS 评分在目标范围内（BPS <5，NPS <3）的平均百分比保持稳定，从 86% 降至 83%（P =.16）。机械通气患者持续使用麻醉剂输注的情况有所减少。这被报告为持续阿片类药物输注的总通气天数的平均百分比：实施前为 65%，实施后为 47%（P <.01）。进行身体活动的 ICU 天数的平均百分比从 24% 增加到 41%（P <.001）。总体平均无通气天数和 ICU 住院时间分别为 5.4 天至 4.5 天（P =.29）和 11.75 天至 9.5 天（P =.20）。