Limits...
Decreasing severe pain and serious adverse events while moving intensive care unit patients: a prospective interventional study (the NURSE-DO project).

de Jong A, Molinari N, de Lattre S, Gniadek C, Carr J, Conseil M, Susbielles MP, Jung B, Jaber S, Chanques G - Crit Care (2013)

Bottom Line: Pain, SAE, patients' characteristics and analgesia were compared among the phases by a multivariate mixed-effects model for repeated-measurements, adjusted on severity index, age, admission type (medical/surgical), intubation and sedation status.Incidence of severe pain decreased significantly from 16% (baseline) to 6% in Phase 3 (odds ratio (OR) = 0.33 (0.11; 0.98), P = 0.04) and 2% in Phase 4 (OR = 0.30 (0.12; 0.95), P = 0.02).Incidence of SAE decreased significantly from 37% (baseline) to 17% in Phase 3 and 21% in Phase 4.

View Article: PubMed Central - HTML - PubMed

ABSTRACT

Introduction: A quality-improvement project was conducted to reduce severe pain and stress-related events while moving ICU-patients.

Methods: The Plan-Do-Check-Adjust cycle was studied during four one-month phases, separated by five-month interphases. All consecutive patients staying more than 24 hours were evaluated every morning while being moved for nursing care (bathing, massage, sheet-change, repositioning). Phase 1 was considered as the baseline. Implemented and adjusted quality-interventions were assessed at phases 2 and 3, respectively. An independent post-intervention control-audit was performed at Phase 4. Primary-endpoints were the incidence of severe pain defined by a behavioral pain scale > 5 or a 0 to 10 visual numeric rating scale > 6, and the incidence of serious adverse events (SAE): cardiac arrest, arrhythmias, tachycardia, bradycardia, hypertension, hypotension, desaturation, bradypnea or ventilatory distress. Pain, SAE, patients' characteristics and analgesia were compared among the phases by a multivariate mixed-effects model for repeated-measurements, adjusted on severity index, age, admission type (medical/surgical), intubation and sedation status.

Results: During the four studied phases, 630 care procedures were analyzed in 53, 47, 43 and 50 patients, respectively. Incidence of severe pain decreased significantly from 16% (baseline) to 6% in Phase 3 (odds ratio (OR) = 0.33 (0.11; 0.98), P = 0.04) and 2% in Phase 4 (OR = 0.30 (0.12; 0.95), P = 0.02). Incidence of SAE decreased significantly from 37% (baseline) to 17% in Phase 3 and 21% in Phase 4. In multivariate analysis, SAE were independently associated with Phase 3 (OR = 0.40 (0.23; 0.72), P < 0.01), Phase 4 (OR = 0.53 (0.30; 0.92), P = 0.03), intubation status (OR = 1.91 (1.28; 2.85), P < 0.01) and severe pain (OR = 2.74 (1.54; 4.89), P < 0.001).

Conclusions: Severe pain and serious adverse events are common and strongly associated while moving ICU patients for nursing procedures. Quality improvement of pain management is associated with a decrease of serious adverse events. Careful documentation of pain management during mobilization for nursing procedures could be implemented as a health quality indicator in the ICU.

Show MeSH

Related in: MedlinePlus

Study-design and quality method. This figure represents the quality-improvement process of pain and serious adverse events while moving ICU patients for turning and nursing care procedures. This 20-month process following the P-D-C-A steps was evaluated by four one-month studied phases separated by inter-study phases of four to six months. The present quality improvement process was the third quality process performed in the ICU regarding the management of sedation and analgesia. Consecutive improvement steps were followed according to the Plan-Do-Check-Adjust method for quality-improvement:- P (Plan-step): Multidisciplinary ICU work group creation, choice of the studied procedure and design of the quality improvement process.- D (Do-step): Beginning of the Nurse-Do study by a one-month baseline evaluation of pain management by nurse while moving the patients (studied Phase 1). Educational interventions for optimized pain management by nurse (Nurse-Do) started after the baseline studied phase.- C (Check step): One-month evaluation (Check) of educational interventions (studied Phase 2).- A (Adjust step): Adjustment of educational interventions implicating an increased multidisciplinary team collaboration, one-month evaluation (Check) of adjusted interventions (studied Phase 3).- Consolidation step: one-month control audit of the PDCA quality improvement process (studied Phase 4).
© Copyright Policy - open-access
Related In: Results  -  Collection

License
getmorefigures.php?uid=PMC3672726&req=5

Figure 1: Study-design and quality method. This figure represents the quality-improvement process of pain and serious adverse events while moving ICU patients for turning and nursing care procedures. This 20-month process following the P-D-C-A steps was evaluated by four one-month studied phases separated by inter-study phases of four to six months. The present quality improvement process was the third quality process performed in the ICU regarding the management of sedation and analgesia. Consecutive improvement steps were followed according to the Plan-Do-Check-Adjust method for quality-improvement:- P (Plan-step): Multidisciplinary ICU work group creation, choice of the studied procedure and design of the quality improvement process.- D (Do-step): Beginning of the Nurse-Do study by a one-month baseline evaluation of pain management by nurse while moving the patients (studied Phase 1). Educational interventions for optimized pain management by nurse (Nurse-Do) started after the baseline studied phase.- C (Check step): One-month evaluation (Check) of educational interventions (studied Phase 2).- A (Adjust step): Adjustment of educational interventions implicating an increased multidisciplinary team collaboration, one-month evaluation (Check) of adjusted interventions (studied Phase 3).- Consolidation step: one-month control audit of the PDCA quality improvement process (studied Phase 4).

Mentions: A multidisciplinary work-group was created, composed of three registered nurses, three assistant nurses, and three physicians (two attending physicians and one resident). All members received institutional education provided by the Hospital Pain Committee. Five meetings were necessary to elaborate the quality study design. The first nursing care procedure in the morning was chosen to be studied because it accounts in our ICU for the care which requires the longest duration of turning, including the largest number of moves and nursing care procedures in the day (bathing, massage of back and pressure points, sheet changing, repositioning, frequent change of dressings and placement of stockings and foot splints). Also, the work group had the impression that there was a strong contrast between the end and beginning of the day regarding pain, agitation and the number of alarms ringing from monitoring systems early in the morning. Contrary to pain at rest, pain during procedures was rarely reported in medical charts. We made the hypothesis that managing procedural pain during the first turning of the day would be the most challenging in our ICU. Figure 1 represents the study design that included four one-month studied phases separated by interphase periods of four to six months, according to the Plan-Do-Check-Adjust method [20-22]. Total length of the study was 20 months. The present quality improvement process was the third quality process performed in the ICU regarding the management of sedation and analgesia. The first quality improvement process, aimed at implementing a systematic assessment of pain and agitation in the ICU using validated tools, was initiated in 2002 and evaluated in 2003 [1]. The second project (2006 to 2007) was aimed at evaluating nurse interventions regarding a sedation-analgesia algorithm and at comparing them to a North American ICU [18].


Decreasing severe pain and serious adverse events while moving intensive care unit patients: a prospective interventional study (the NURSE-DO project).

de Jong A, Molinari N, de Lattre S, Gniadek C, Carr J, Conseil M, Susbielles MP, Jung B, Jaber S, Chanques G - Crit Care (2013)

Study-design and quality method. This figure represents the quality-improvement process of pain and serious adverse events while moving ICU patients for turning and nursing care procedures. This 20-month process following the P-D-C-A steps was evaluated by four one-month studied phases separated by inter-study phases of four to six months. The present quality improvement process was the third quality process performed in the ICU regarding the management of sedation and analgesia. Consecutive improvement steps were followed according to the Plan-Do-Check-Adjust method for quality-improvement:- P (Plan-step): Multidisciplinary ICU work group creation, choice of the studied procedure and design of the quality improvement process.- D (Do-step): Beginning of the Nurse-Do study by a one-month baseline evaluation of pain management by nurse while moving the patients (studied Phase 1). Educational interventions for optimized pain management by nurse (Nurse-Do) started after the baseline studied phase.- C (Check step): One-month evaluation (Check) of educational interventions (studied Phase 2).- A (Adjust step): Adjustment of educational interventions implicating an increased multidisciplinary team collaboration, one-month evaluation (Check) of adjusted interventions (studied Phase 3).- Consolidation step: one-month control audit of the PDCA quality improvement process (studied Phase 4).
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3672726&req=5

Figure 1: Study-design and quality method. This figure represents the quality-improvement process of pain and serious adverse events while moving ICU patients for turning and nursing care procedures. This 20-month process following the P-D-C-A steps was evaluated by four one-month studied phases separated by inter-study phases of four to six months. The present quality improvement process was the third quality process performed in the ICU regarding the management of sedation and analgesia. Consecutive improvement steps were followed according to the Plan-Do-Check-Adjust method for quality-improvement:- P (Plan-step): Multidisciplinary ICU work group creation, choice of the studied procedure and design of the quality improvement process.- D (Do-step): Beginning of the Nurse-Do study by a one-month baseline evaluation of pain management by nurse while moving the patients (studied Phase 1). Educational interventions for optimized pain management by nurse (Nurse-Do) started after the baseline studied phase.- C (Check step): One-month evaluation (Check) of educational interventions (studied Phase 2).- A (Adjust step): Adjustment of educational interventions implicating an increased multidisciplinary team collaboration, one-month evaluation (Check) of adjusted interventions (studied Phase 3).- Consolidation step: one-month control audit of the PDCA quality improvement process (studied Phase 4).
Mentions: A multidisciplinary work-group was created, composed of three registered nurses, three assistant nurses, and three physicians (two attending physicians and one resident). All members received institutional education provided by the Hospital Pain Committee. Five meetings were necessary to elaborate the quality study design. The first nursing care procedure in the morning was chosen to be studied because it accounts in our ICU for the care which requires the longest duration of turning, including the largest number of moves and nursing care procedures in the day (bathing, massage of back and pressure points, sheet changing, repositioning, frequent change of dressings and placement of stockings and foot splints). Also, the work group had the impression that there was a strong contrast between the end and beginning of the day regarding pain, agitation and the number of alarms ringing from monitoring systems early in the morning. Contrary to pain at rest, pain during procedures was rarely reported in medical charts. We made the hypothesis that managing procedural pain during the first turning of the day would be the most challenging in our ICU. Figure 1 represents the study design that included four one-month studied phases separated by interphase periods of four to six months, according to the Plan-Do-Check-Adjust method [20-22]. Total length of the study was 20 months. The present quality improvement process was the third quality process performed in the ICU regarding the management of sedation and analgesia. The first quality improvement process, aimed at implementing a systematic assessment of pain and agitation in the ICU using validated tools, was initiated in 2002 and evaluated in 2003 [1]. The second project (2006 to 2007) was aimed at evaluating nurse interventions regarding a sedation-analgesia algorithm and at comparing them to a North American ICU [18].

Bottom Line: Pain, SAE, patients' characteristics and analgesia were compared among the phases by a multivariate mixed-effects model for repeated-measurements, adjusted on severity index, age, admission type (medical/surgical), intubation and sedation status.Incidence of severe pain decreased significantly from 16% (baseline) to 6% in Phase 3 (odds ratio (OR) = 0.33 (0.11; 0.98), P = 0.04) and 2% in Phase 4 (OR = 0.30 (0.12; 0.95), P = 0.02).Incidence of SAE decreased significantly from 37% (baseline) to 17% in Phase 3 and 21% in Phase 4.

View Article: PubMed Central - HTML - PubMed

ABSTRACT

Introduction: A quality-improvement project was conducted to reduce severe pain and stress-related events while moving ICU-patients.

Methods: The Plan-Do-Check-Adjust cycle was studied during four one-month phases, separated by five-month interphases. All consecutive patients staying more than 24 hours were evaluated every morning while being moved for nursing care (bathing, massage, sheet-change, repositioning). Phase 1 was considered as the baseline. Implemented and adjusted quality-interventions were assessed at phases 2 and 3, respectively. An independent post-intervention control-audit was performed at Phase 4. Primary-endpoints were the incidence of severe pain defined by a behavioral pain scale > 5 or a 0 to 10 visual numeric rating scale > 6, and the incidence of serious adverse events (SAE): cardiac arrest, arrhythmias, tachycardia, bradycardia, hypertension, hypotension, desaturation, bradypnea or ventilatory distress. Pain, SAE, patients' characteristics and analgesia were compared among the phases by a multivariate mixed-effects model for repeated-measurements, adjusted on severity index, age, admission type (medical/surgical), intubation and sedation status.

Results: During the four studied phases, 630 care procedures were analyzed in 53, 47, 43 and 50 patients, respectively. Incidence of severe pain decreased significantly from 16% (baseline) to 6% in Phase 3 (odds ratio (OR) = 0.33 (0.11; 0.98), P = 0.04) and 2% in Phase 4 (OR = 0.30 (0.12; 0.95), P = 0.02). Incidence of SAE decreased significantly from 37% (baseline) to 17% in Phase 3 and 21% in Phase 4. In multivariate analysis, SAE were independently associated with Phase 3 (OR = 0.40 (0.23; 0.72), P < 0.01), Phase 4 (OR = 0.53 (0.30; 0.92), P = 0.03), intubation status (OR = 1.91 (1.28; 2.85), P < 0.01) and severe pain (OR = 2.74 (1.54; 4.89), P < 0.001).

Conclusions: Severe pain and serious adverse events are common and strongly associated while moving ICU patients for nursing procedures. Quality improvement of pain management is associated with a decrease of serious adverse events. Careful documentation of pain management during mobilization for nursing procedures could be implemented as a health quality indicator in the ICU.

Show MeSH
Related in: MedlinePlus