Results of implementing a pain management algorithm in intensive care unit patients: The impact on pain assessment, length of stay, and duration of ventilation

doi:10.1016/j.jcrc.2016.07.011

Journal of Critical Care

Volume 36, December 2016, Pages 207-211

https://doi.org/10.1016/j.jcrc.2016.07.011 Get rights and content

Abstract

Purpose

This study aimed to measure the impact of implementing a pain management algorithm in adult intensive care unit (ICU) patients able to express pain. No controlled study has previously evaluated the impact of a pain management algorithm both at rest and during procedures, including both patients able to self-report and express pain behavior, intubated and nonintubated patients, throughout their ICU stay.

Materials and methods

The algorithm instructed nurses to assess pain, guided them in pain treatment, and was implemented in 3 units. A time period after implementing the algorithm (intervention group) was compared with a time period the previous year (control group) on the outcome variables: pain assessments, duration of ventilation, length of ICU stay, length of hospital stay, use of analgesic and sedative medications, and the incidence of agitation events.

Results

Totally, 650 patients were included. The number of pain assessments was higher in the intervention group compared with the control group. In addition, duration of ventilation and length of ICU stay decreased significantly in the intervention group compared with the control group. This difference remained significant after adjusting for patient characteristics.

Conclusion

Several outcome variables were significantly improved after implementation of the algorithm compared with the control group.

Introduction

Many patients in intensive care units (ICUs) experience pain [1], [2]. Pain should be assessed routinely and repetitively [3] but is not always done [4]. Valid pain assessment tools are available and recommended [3], but a substantial proportion of ICU nurses do not use them [5]. When implementing these tools in clinical practice, knowledge deficits, resistance, and barriers against changing practice have been documented among clinicians [6], [7], [8], [9].

Clinical evidence-based algorithms are suitable for implementing pain management in clinical practice [10]. However, because an appropriate algorithm for adult ICU patients that included both pain assessment and pain management was not available, a comprehensive new algorithm was developed [11]. This algorithm was implemented in 3 units [12]. To our knowledge, no controlled studies have previously evaluated the impact of a pain management algorithm both at rest and during procedures [13], including both patients able to self-report and express pain behavior, intubated and nonintubated patients, throughout their ICU stay.

However, the implementation of a single pain assessment tool has been evaluated in several studies [14], [15], [16], [17]. Of note, not all ICU patients able to express pain were included in these studies. Other studies have evaluated the implementation of several assessment tools, including tools to assess pain, agitation, and delirium [18], [19], [20], [21]. When introducing several tools targeting different variables, it is difficult to evaluate the effect of implementing the pain assessment tools. Despite these limitations, these studies found a decrease in pain and agitation [17], [20], decreased duration of ventilation [15], [18], [19], [20], decreased length of ICU stay [14], [15], [18], [19], decreased length of hospital stay [18], a decrease in complications [15], nosocomial infections [20], decreased mortality [18], [19], more frequently charted pain assessments in the medical records [14], [15], [16], [17], [20], and better and more dedicated analgesia [14], [15], [16], [18], [20], [21].

Based on earlier research, the objective of the present study was to evaluate the use of a pain assessment and pain management algorithm in all groups of ICU patients able to express pain on pain assessments, duration of ventilation, length of ICU stay, length of hospital stay, use of analgesic and sedative medications, and the incidence of agitation events.

Section snippets

Development of the algorithm

A short, evidence-based algorithm was developed [11]. The algorithm instructed ICU nurses to assess patients' pain at least once a shift, both at rest and during turning [22], [23]. A numeric rating scale (NRS) was used when patients could self-report pain [24]. The behavioral pain scale (BPS) was used when patients were receiving mechanical ventilation and unable to self-report pain [25]. Finally, the BPS-NonIntubated (BPS-NI) was used when patients were not intubated but unable to self-report

Results

To ensure that there were at least 117 mechanically ventilated patients in each group, we included 650 patients overall. The intervention group (n = 398) and the control group (n = 252) were similar regarding sex, age, diagnoses, and use of ventilation. Patients in the intervention group had significantly lower disease severity (SAPS, 36 vs 40; P = .02) and lower nursing workload (NEMS, 31 vs 36; P < .001) compared with those in the control group (Table 1).

In the intervention group, 4223 pain

Discussion

To our knowledge, no controlled studies have previously evaluated the impact of a comprehensive pain management algorithm both at rest and during procedures, including both patients able to self-report and express pain behavior, intubated and nonintubated patients, throughout their ICU stay. The patient mix and the staff were the same for the 2 study periods, and the included units did not implement new medications or new procedures for weaning from mechanical ventilation between these 2 study

Conclusion

The implementation of a pain management algorithm in adult ICU patients able to express pain was associated with a higher number of pain assessments and a decreased duration of ventilation and length of ICU stay. This algorithm detects and treats pain at rest and during turning, based on the assessment of pain with validated tools specifically dedicated to patients' condition throughout their ICU stay (intubated/nonintubated and able/unable to self-report pain). These findings could have an

Acknowledgment

We would like to thank all the nurses who participated in and contributed to the study. We acknowledge the South-Eastern Norway Regional Health Authority, Østfold Hospital Trust, and Oslo University Hospital for funding the study.

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Nurse's Evaluation of a Pain Management Algorithm in Intensive Care Units
2020, Pain Management Nursing
Citation Excerpt :
The nurses’ level of adherence to the algorithm during this period was high, as nurses assessed pain during 75% of the shifts in which the algorithm suggested pain assessment (Olsen et al., 2015b). Several outcome variables, such as the number of pain assessments, duration of ventilation, and length of ICU stay, improved significantly after implementation of the pain-management algorithm, compared with an ICU patient control group in which pain was not assessed using the algorithm (Olsen, Rustoen, Sandvik, Jacobsen, & Valeberg, 2016). This study was a descriptive survey.
Many patients have memories of pain during intensive care unit stay. To improve pain management, practice guidelines recommend that pain management should be guided by routine pain assessment and suggest an assessment-driven, protocol-based, stepwise approach. This recommendation prompted the development of a pain-management algorithm.
Evaluate the feasibility and clinical utility of this algorithm.
A descriptive survey.
One medical/surgical intensive care unit, one surgical intensive care unit, and one postanesthesia care unit at two hospitals in Norway.
Nurses working at the three units.
A pain-management algorithm, including three pain assessment tools and a guide to pain assessment and pain management, was developed and implemented in three intensive care units. Nurses working at the three units (n = 129) responded to a questionnaire regarding the feasibility and clinical utility of the algorithm used.
Our results suggested that nurses considered the new pain-management algorithm to have relatively high feasibility, but somewhat lower clinical utility. Less than half of respondents thought that pain treatment in clinical practice had become more targeted using the tree pain-assessment tools (45%) and the algorithm for pain assessment and pain management (24%).
Pain-management algorithms may be appropriate and useful in clinical practice. However, to increase clinical utility and to achieve more targeted pain treatment, more focus on pain-treatment actions and reassessment of patients’ pain is needed. Further focus in clinical practice on how to implement an algorithm and more focus on pain-treatment action and reassessment of patients’ pain is needed.
Management of analgesia, sedation and delirium in Spanish Intensive Care Units: A national two-part survey
2019, Medicina Intensiva
Conocer la práctica clínica real de las UCI españolas en relación con la analgosedación y delirium, y valorar cómo se ajusta a las recomendaciones actuales.
Estudio transversal descriptivo elaborado mediante encuesta nacional sobre prácticas de analgosedación y delirium de los pacientes ingresados en UCI los días 16 de noviembre de 2013 y 16 de octubre de 2014. Se envió un cuestionario a través de Internet con el aval de la SEMICYUC.
UCI tanto públicas como privadas de todo el territorio nacional.
Se incluyeron un total de 166 UCI y a 1.567 pacientes. El 61,4% de las UCI contaban con un protocolo de sedación. El 75% de las UCI monitorizaban la sedación y agitación, con RASS como la escala empleada con mayor frecuencia. El dolor se monitorizaba en algo más de la mitad de las UCI, pero las escalas conductuales eran de muy baja implantación. El delirium también presentaba un bajo nivel diagnóstico. Entre los pacientes en ventilación mecánica el midazolam continuaba siendo un sedante de muy amplio uso.
Esta encuesta es la primera realizada en España sobre analgosedación y delirium y nos muestra una fotografía sobre estas prácticas, señala algunos aspectos como los relacionados con la monitorización y usos de escalas, junto con el manejo del delirium, en los que los resultados del estudio animan a desarrollar proyectos docentes que acerquen la práctica clínica real a las recomendaciones nacionales e internacionales.
To know the real clinical practice of Spanish ICUs in relation to analgesia, sedation and delirium, with a view to assessing adherence to current recommendations.
A descriptive cross-sectional study was carried out based on a national survey on analgesia, sedation and delirium practices in patients admitted to intensive care on 16 November, 2013 and 16 October, 2014. An on-line questionnaire was sent with the endorsement of the SEMICYUC.
Spanish ICUs in public and private hospitals.
A total of 166 ICUs participated, with the inclusion of 1567 patients. The results showed that 61.4% of the ICUs had a sedation protocol, and 75% regularly monitored sedation and agitation - the RASS being the most frequently used scale. Pain was monitored in about half of the ICUs, but the behavioral scales were very little used. Delirium monitoring was implemented in few ICUs. Among the patients on mechanical ventilation, midazolam remained a very commonly used agent.
This survey is the first conducted in Spain on the practices of analgesia, sedation and delirium. We identified specific targets for quality improvement, particularly concerning the management of sedation and the assessment of delirium.
Intraoperative Onabotulinumtoxin-A Reduces Postoperative Narcotic and Anticholinergic Requirements After Continent Bladder Reconstruction
2018, Urology
Citation Excerpt :
Bladder reconstruction is a complex operation that often involves both the urinary system and the gastrointestinal system, leading to a prolonged hospital course as both systems recover. Adequate postoperative pain control and awaiting return of bowel function are major contributors to prolonged length of hospital stay.10,11 Patients undergoing bladder reconstruction are at particularly high risk for these contributors to be significant factors because of the nature of the extensive bladder and bowel dissection and the use of abdominal retractors.
To determine if intradetrusor injection of onabotulinumtoxin-A (BTX-A) would reduce postoperative narcotic and anticholinergic requirements in children undergoing open continent bladder reconstruction.
After institutional review board approval, we retrospectively reviewed all bladder reconstructions performed. Bladder reconstruction was defined as the following procedures in any combination: bladder neck reconstruction and sling, bladder neck closure, Mitrofanoff, Monti, or bladder augmentation. We identified 15 children who underwent reconstruction with BTX-A injection and compared these with 15 children who did not receive BTX-A. Postoperative narcotic and anticholinergic requirements were recorded as well as length of stay, time to diet, time to return of bowel function, and complications. All medications were converted to morphine mEq/kg per day or mg/kg per day to standardize for patient size and length of stay.
Thirty patients who underwent open bladder reconstruction were included. Fifteen received BTX-A injection and 15 did not. The BTX-A group required significantly less narcotic medication postoperatively compared with the no-BTX-A group (0.32 vs 0.85 morphine mEq/kg per day; P = .0002). The BTX-A group also required significantly less anticholinergic medication compared with the no-BTX-A group (0.22 vs 0.88 mg/kg per day; P = .024). There was no significant difference between the groups with respect to length of stay (98.27 vs 9.287 days; P = .34) or return of bowel function (5.53 vs 4.93 days; P = .994). Complication rate between the groups was similar (P >.99).
Intraoperative injection of BTX-A significantly reduced postoperative narcotic and anticholinergic requirements in patients who underwent open continent bladder reconstruction. This is an encouraging alternative treatment to manage postoperative pain with no associated risk of significant complications.
Impact of a Clinical Therapeutic Intervention on Pain Assessment, Management, and Nursing Practices in an Intensive Care Unit: A before-and-after Study
2018, Pain Management Nursing
Citation Excerpt :
Our data suggest that before protocol adoption, patients received excessive sedation and insufficient analgesia. The implementation of decision-making algorithms and protocols in intensive care can have a positive effect on patient outcomes (Olsen et al., 2015; Olsen, Rustøen, Sandvik, Jacobsen, & Valeberg, 2016). Reduction of sedation and more effective pain management have the potential to exert beneficial effects on the post-ICU course (Barr & Pandharipande, 2013; Payen et al., 2001).
Background: Accurate pain assessment and management constitute a major challenge for medical and nursing staff in intensive care units (ICUs). A distinct recollection of pain is reported by high proportions of ICU patients. Purpose: A clinical therapeutic intervention directed at improving pain assessment and management in critically ill patients who are unable to communicate was implemented at an Italian ICU. Methods: In this before-and-after study, data were collected before (T₀) and after (T₁) the adoption of a protocol involving pain assessment with an ad hoc behavioral pain scale and the administration of analgesics, rather than sedatives, to patients with intermediate to high pain scores. Results: The main outcome measure was pain recollection a year after discharge; secondary outcome measures were the use and doses of sedatives and analgesics. A significantly (p = .037) smaller proportion of patients treated after protocol adoption recollected feeling severe pain compared with patients treated before the protocol was introduced. This group also received significantly (p < .001) fewer sedatives and significantly (p = .0028) more anti-inflammatory drugs and analgesics on an “as needed” basis. The administration of strong analgesics was similar in the two groups. The intervention was implemented in 70.5% of patients with intermediate to high pain scores. Conclusions: Appropriately trained ICU nurses have the potential to help adopt pain relief and prevention measures during nursing care and to contribute to the successful management of sedation and analgesia. Further studies of larger patient samples are needed to monitor the stability of results over time and to explore the efficacy of the approach in other populations, such as pediatric and neonatal ICU patients.
The Trajectory of Postoperative Pain Following Mastectomy with and without Paravertebral Block
2017, Pain Management Nursing
Citation Excerpt :
In addition to testing interventions for the treatment of pain, nonparticipant observational research, directed toward understanding practice-based barriers to assessment and effective implementation of pain relief, is required. Contemporary studies explore the use of algorithms (Botti et al., 2014; Olsen, Rustoen, Sandvik, Jacobsen, & Valeberg, 2016) to standardize care processes and improve the quality of pain management. Algorithms provide guidance for the prescription and administration of multimodal analgesics in the postoperative period, for the management of breakthrough pain, and for benchmarking practice with settings in which these are not in use through comparative studies.
Evidence to support the argument that general anesthesia (GA) with paravertebral block (PVB) provides better pain relief for mastectomy patients than GA alone is contradictory. The aim of this study was to explore pain and analgesia after mastectomy with or without PVB during acute inpatient recovery. A retrospective study was conducted in a single hospital providing specialist cancer services in metropolitan Melbourne, Australia. We explored pain and concomitant analgesic administration in 80 consecutive women recovering from mastectomy who underwent GA with (n = 40) or without (n = 40) PVB. A pain management index (PMI) was derived to illustrate the efficacy of management from day of surgery (DOS) to postoperative day (POD) 3. Patients who reported no pain progressively increased from DOS (n = 12, 15%) to POD 3 (n = 54, 67.5%). Most patients were administered analgesics as a combination of acetaminophen and a strong opioid on DOS (n = 53, 66.2%), POD 1 (n = 45, 56.2%), POD 2 (n = 33, 41.2%), and POD 3 (n = 21, 26.2%). Less than 6% of patients on any POD were administered multimodal anlagesics. PMI scores indicate some pain in the context of receiving weak and strong opioids for GA patients and more frequent use of nonopioid analgesics in PVB patients during recovery. These findings highlight the need for data describing patterns of analgesic administration in addition to reports of postoperative pain to determine the most effective means of avoiding postoperative pain in patients who require mastectomy.
Authorized agent–controlled analgesia for pain management in critically ill adult patients
2020, Critical Care Nurse
Patient-controlled analgesia is commonly used for adult patients requiring parenteral opioid analgesia in the postoperative setting. However, many patients are unable to use patient-controlled analgesia because of physical or cognitive limitations. Authorized agent–controlled analgesia, in which a nurse or family member activates the patient-controlled analgesia device, has been studied in the pediatric population but has received little attention in adults.
To evaluate the efficacy of authorized agent–controlled analgesia in critically ill adult patients.
A retrospective pilot study was conducted involving 46 patients who were placed on an authorized agent–controlled analgesia protocol in a mixed medical/surgical adult intensive care unit. Critical-Care Pain Observation Tool scores were abstracted for the 24 hours before and after initiation of authorized agent–controlled analgesia. Authorized agent–controlled analgesia was administered by nurses only.
The mean (SD) change in pain score was –3.4 (2.0) (95% CI, –4.0 to –2.7), representing a 69% decrease in the mean (SD) pain score from before to after initiation of authorized agent–controlled analgesia (4.8 [1.8] vs 1.5 [1.6]; P <.001). When the results were controlled for time, sedative administration, and opioid medication administration, the effect of authorized agent–controlled analgesia initiation on pain scores remained significant (P <.001).
Use of authorized agent–controlled analgesia is associated with a reduction in pain in critically ill patients. Larger studies are warranted to confirm these findings.

View all citing articles on Scopus

^☆: Disclosure of funding: the authors do not have any ethical conflicts or financial interests to disclose. South-Eastern Norway Regional Health Authority, Østfold Hospital Trust, and Oslo University Hospital funded this study.

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Outcomes/PredictionsResults of implementing a pain management algorithm in intensive care unit patients: The impact on pain assessment, length of stay, and duration of ventilation☆

Abstract

Purpose

Materials and methods

Results

Conclusion

Introduction

Section snippets

Development of the algorithm

Results

Discussion

Conclusion

Acknowledgment

Intensive Crit Care Nurs

Injury

Pain Manag Nurs

Intensive Crit Care Nurs

Pain Manag Nurs

Heart Lung

Heart Lung

Int J Nurs Stud

J Crit Care

Pain

Br J Anaesth

Am J Med

Anaesth Crit Care Pain Med

Patients' recollections of stressful experiences while receiving prolonged mechanical ventilation in an intensive care unit

Crit Care Med

Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit

Crit Care Med

Current practices in sedation and analgesia for mechanically ventilated critically ill patients: a prospective multicenter patient-based study

Anesthesiology

Critical care nurses' pain assessment and management practices: a survey in Canada

Am J Crit Care

Influences of patient behavior on clinical nurses' pain assessment: implications for continuing education

J Contin Educ Nurs

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

Crit Care

Behavioral pain assessment tool for critically ill adults unable to self-report pain

Am J Crit Care

Impact of the implementation of the critical-care pain observation tool (CPOT) on pain management and clinical outcomes in mechanically ventilated trauma intensive care unit patients: a pilot study

J Trauma Nurs

Outcomes/Predictions
Results of implementing a pain management algorithm in intensive care unit patients: The impact on pain assessment, length of stay, and duration of ventilation☆