I'm Michelle Ballas. Greetings from the great state of Ohio. I'm so happy that many of you here are from the state. I have to say I wanted to start by saying I got y'all's back. You guys were complaining before about minus one, minus two. I came from Omaha, Nebraska where it was minus 25 when I left, so I kind of I think I have the record for most change and now to this beautiful humidity and no sun. The other thing I wanted to bring up when I heard people talking before is whoever mentioned about the interest in implementation science, come see me, and also the question regarding certification. I don't know if you understand the magnitude of what you're doing right now. You guys should be super excited. You are the first group of providers in the world, in the world, that are going to have certification in the A-F bundle. That is fantastic and really it's something that you should take great pride in. Why do you care? Somebody's like, well what's the difference with the certification? There's a lot of difference, right? When you go back and you teach your ICU providers these things, you're teaching them evidence-based practice. People still rely on those myths that we had from years and years ago. You hear that when we have all the question and answer session. You're teaching them the latest evidence. Well, why does that care? Well, we know it matters in terms of quality and safety, right? If you do this stuff and you get your ICU providers to do this stuff, management's going to be happy. Your ventilator associated vent rates will go down. Your complications will go down. Who deals with pressure ulcers? There's got to be some nurses in here that are responsible for monitoring pressure ulcers. You would expect pressure ulcer rates to go down. Restraint rates to go down. You know, there's talk at a national level in terms of policy about monitoring antipsychotic use now in hospitals. You're going to be hitting all of the quality metrics the big wigs in your hospital care about, but more importantly, you are the first ever to go through this. So I just wanted to say, wow, congratulations. It's a great thing. You should be really, really proud of yourself. I'm here to show you what you're going to be teaching your staff in regards to the A bundle, the A part of the bundle. In terms of disclosures, how cool is this? Our team, many of who are in the room, Wes, Brenda, Lori, I don't know if Lori's here, we just received a grant from the National Heart and Lung, NHLBI Institute, an R01, that is going to be looking at answering a lot of the questions you guys have right now. So the grant that we're going to be working on in the next two years is looking at what are the factors. We know the bundle works. That's kind of a mute point. Once you see the data, and it'll be throughout the presentations, you'll be very impressed with the data. It's kind of a mute point now. The interventions in the bundle work, we know that from randomized control trials. We know the quality improvement projects that have been done throughout the nation show you get all of these different benefits. The problem is, as you know, getting it into practice. So the grant we received is going to be looking at how do we get it into practice? What are the patient, provider, and system level factors that are associated with effective adoption? We're going to give you some hints on that throughout all the presentations that you have. The other difficult challenge in presenting to this group is I hear many of you have never gone through the course before, and some of you are already considered probably super users, right? Gone through the class, here now, so that you can bring it even for practice up further. So even though we won't cover every slide in detail, because you guys are a brilliant group of providers, and I think we get a lot of learning that's occurring through these questions and answers, these slides are here for your reference. These, I think, and correct me if I'm wrong, Christina, or... I think these are the slides you'll be using for your teaching, right? So if you have any questions when you see something up there, just let me know, but the reference list that composes the evidence behind the A slide, I think, is like two to three pages long, and we have copies of that for you as well, okay? So where do we start? Well as Wes told you at the beginning of his presentation, the A part of the bundle was kind of recently changed, right? Before it was awakening trials. Well now the new A is the assessment, prevention, and management of pain, and it came about because of the new PATI's guidelines and the emphasis that we're seeing across the world about how urgent it is to address and manage pain appropriately. Many of my Ohio friends know, unfortunately, we are the state with the leading overdose rates in the country, so there's been a lot of attention on opioids, and I'm sure all of your questions are going to be around now the restrictions that are coming around, the use of opioids, and some policy changes that have been happening at the hospital level that may affect pain management. But that attention is one of the reasons that the bundle was changed to be congruent with the PATI guidelines, and also everybody knows who's practiced a day in their life in the ICU, the importance of pain. We know that patients have pain both at rest and with activity. That might be a new teaching point for some of your particularly novice providers, right? Sometimes people equate like if the patient's not actively moving and groaning and grabbing at their incisions or their ET tube or something, but even at rest we know ICU patients have pain. We know that certain factors are associated with pain. If you have surgery, duh, right? You have an incision, you're having a procedure, we know that they're painful. We know if patients come to us with pre... anybody ever care for a patient in their ICU that might have a psych or mental health comorbidity? I know they're rare, and I know that every ICU actually across the country thinks that they deal with the most drug abusers in the country. If I put up my hands, who has the most? Oh, I do. Everybody in the country thinks that, but we know that unfortunately we do have a significant psych mental health crisis in our country, and that patients come to us with pre-existing psychological conditions, right? So if they come to you with anxiety or with depression or with psychosis and you inadvertently stop their antipsychotic medications, we may run into problems. So there are factors that increase patients risk for pain that we sometimes don't think about because we're in that immediate old school airway breathing circulation thinking that affect our ability to manage it. There are a number of studies, I think at my last count there was 44 that looked at the effects of pain or the association, because you really don't randomize ICU patients to let's give them a lot of pain and see what happens, but there's been a lot of studies that looked at what happens in terms of longer-term outcomes when patients experience pain in the ICU. Some great work about traumatic memories. Interesting when you read that work, a lot of it involves males remembering incorrectly, I assume, that they were raped in the ICU, but a lot of traumatic memories that affect people for years once they're out of the ICU. The physical morbidities that come along with it, but again that the psychological comorbidity consequences are huge. PTSD, the cognitive impairment, the chronic pain. Lots of great work coming out on that. So we know it's challenging to manage. The new pack, I don't know if you guys have all seen the copies of the new Patty's guidelines, but they actually have pain. I think had the most recommendations or statements at least for any of the symptoms that the Patty's guidelines addressed, right? So 33% of the Patty's guidelines deal with pain. That's pretty impressive and again it reflects the interprofessional nature. So you'll see this slide probably a billion times. We're focusing on the A right now, the assessment prevention and management of pain. One of the things people often ask is, you know, how... when we're talking about the effects the bundle has and the guidelines have, how did we define assessment prevention and management of pain in the ICU Liberation Collaborative that we did? We had to have something operationalized that was easily and consistently measured across all 68 ICUs that took part in the collaborative and our analyses that we've published so far to date, when we talk about A, we're really just talking about the assessment part, right? Because we define assessment of pain as done if the patient had greater than six pain assessments per day using a valid and reliable tool. Where did we come up with that greater than six times a day? Well, quite honestly we made it up, right? It was a back-and-forth between everybody. Should it be every one hour? Should it be every two hours? Should it be every... and so the group consensus came that this is a pretty realistic definition in terms of workflow, workload issues. Obviously you can do it more often, but this was kind of what we came up with. The pain assessment and particularly the sedation assessments do apply to both vent and non-mechanically ventilated and non-mechanically ventilated patients. We will be talking about the tools that you'll be teaching your staff to use in terms of the pain assessments. So this is pretty neat data. I don't know if we talked about this. This is our performance data that we'll probably be revising shortly based on some great reviewer comments we just received. But this is what happened over the course of that 18-month collaborative that we were talking about, the ICU Liberation Collaborative. So we had these 68 centers, topped in the bundle, gave them all the resources. Well what happened? Did it affect practice? And here's some of our data. Again, might be a little bit revised, but some really great teaching points in here. First of all, you can see that baseline period is around 3%, right? So when we measured complete performance, meaning the patient got every part of the bundle every time they were eligible, only 3% of these highly motivated, genius, great ICUs that participated, 3% nationally. The good news is after working with us and learning from each other, like you guys are doing here today, we tripled the performance of the ABCDF bundle. That's huge, right? Tripled? Who's the doubting Thomas guy in the green? You know it. The tripling means we got to a 12% rate, right? Around there. So great opportunities. When we look at proportional performance, we're doing much better. So proportional meaning they're getting parts of the bundle. And look at this slide, how neat it is. I have it in this because it reflects every... this part in because it reflects all the bundle elements that you're here today. A is the best, right? So then we looked at, well where are we as a nation in terms of delivering these evidence-based interventions? Really important question in my head. A, you'll see, we're pretty... we're the best in A. So by the end of the collaborative, we got close to a 90% adherence rate to the greater than six a day pain assessments using valid and reliable tools. That's good, right? Not surprisingly, you'll see the E. Still down there, the lowest. Wasn't too surprising to anybody. I cannot explain the SAT and the SBT part. Why they remain so low. Now a lot of it does come down to operational definitions, right? We just simply said, was the patient on sedation? Did they get it off, shut off that day? Yes, no. We didn't talk about those safety screen criteria or anything like that. So we know that there will be patients in the United States every day that should not have an SAT or an SBT, right? We don't know exactly what that proportion is, but my gut, if you're looking at these things, it's not going to be 70% of our patients. And SBT, ironically, has the most evidence behind any of the interventions. So why are we not doing SBTs? But that's another lecture. Anyway, pretty neat data, right? So when you struggle and you go back and you're trying so hard, you're... this is over an 18-month period as well. It's going to take time to get this stuff done. And we know that you're not alone. You're not a loser. You're not the only one having issues with this. Again, highly motivated sites getting a great amount of support and still challenged nationally. Suggesting the need for more research on how do we get these people to do what we want them to do, right? How do we deliver them evidence-based cures? Because right now, over 80% of the patients aren't getting the best care that we know is possible. So, okay. So in terms of your teaching for ICU pain, the emphasis on subjective. A lot of this won't be new for nurses. I know this is Undergraduate Nursing 101, right? Pain is what people tell you their pain is. Many people equate that... that the construct of pain being multi-dimensional and it really is. It has that physiologic component. It has that psychological component. It has all that history people bring with it. And it also has behaviors, cultural differences in way pain is expressed, right? Have you seen that in your clinical practice? Different cultures manifest pain in different ways. The emphasis you're going to be teaching is this stepwise approach, right? We're going to... and you're going to see these repeated over and over, over. We're going to do steps. The gold standard is self- report. We want our patients to tell us that they're having pain. That's the best way, the most accurate way to determine if your patient's having pain. From the literature, we know that those numeric rating scales that we've used, again, pretty consistently, 0 to 10. No pain, worst pain possible. Really great to use. A lot of people have some confusion over how do you... and we're going to be talking about the JACO because that's a huge, huge, huge issue right now. Tons of listservs right now about this JACO issue that's happening with the sedatives and the opioids in the ICU and vasopressors. So we will talk about that. But mild pain being from like 1 to 3. Significant pain, greater than 3. But those numbers are important when you're going back and you're looking at your institutional policies to make sure that they're consistent with the literature and how you're writing your orders for pain management. It's also okay to ask your patients simply, are you having pain? And if they say yes, guess what? They're likely having pain. You can explore more, but it is acceptable to accept a patient telling you, yes, I have pain. Some tools. You need these tools. You have to have these tools available in your ICU for the nurses to use or whoever wants to use them. Our respiratory therapist friends have been really actively involved in helping better pain assessment and management. But having those cards, the numeric rating scale cards, some people use the thermometers, right? Having that access to those tools is important so patients can actually... I mean, how are you doing that if they're not able to point? You could try to lip read, right? Doesn't seem unreasonable, but having them able to point would be good and it also gets them out of restraints for a minute. But having them on the tool... having them on your unit available to nurses in an infection control kind of way would be important. Our goal is the alert and oriented patient who can tell us yes or no they're having pain. In those patients that can't tell us they're having pain, we're going to be using the tools, the behavioral pain scale tools. And the PADI's guidelines recommend tool, two of those tools, the BPS and the CPOT. How many of you use the BPS? One? CPOT? Anybody use something different? What is it? A nonverbal pain score? Oh, okay. So the nonverbal pain scale. Yes, okay. These are the two that are recommended and I have reference to that slide in here too, that are recommended as most valid by the PADI's guidelines and have shown to be most valid and reliable. They have been used for monitoring pain, medical. I hear medical people, surgical, post-operative, trauma patients, brain injury patients. There are some evidence. There is some evidence for use and I'll show you that slide in a minute. But they've been shown to be valid and reliable for those patients that can't self-report. You'll need to teach your providers how to use these tools, right? So here's an example. This is the behavioral pain scale. Measures the facial expression, upper limb movement, compliance with ventilator. Kind of seems intuitive of how to use, right? Doesn't look too hard. In terms of the BPS, the scores range from 3 to 12 and significant pain is anything greater than a 5, okay? Now it's going to be a major teaching point coming up. So BPS 5. Some examples if you want to use in your teaching. The CPOT is also a behavioral pain scale. That one ranges from 0 to 8 with CPOT greater than 2, meaning the patient has significant pain. What's important when you're going back and teaching? The behavioral pain scores that you get, it's not the same as a self-report. So if you get an 8 on the CPOT, that's not an 8 on a numeric pain rating scale. You can't compare the two. Some people do, right? They make the mistake and they do that. You can't interchange the BPS for the CPOT. That sometimes happens as well. Those behaviors that you're seeing, if you're seeing them, if your patients aren't, you know, deeply deeply sedated, like we know vast majority of patients remain, they're really looking at those behaviors. So the patient, you know, is doing something to show you that they're having pain. And in terms of how you're using them with the... they have been used. I have an example at the very end that you can bring back to your institutions of how you could write your PRN orders around them as well. Because a lot of institutions have had difficulty with that. I feel like I'm ignoring you guys over here, sorry. So the numeric rating scale, then you can do the behavioral pain scales if you can't do that. Is it okay to ask family members or involve them at least in pain assessment? Sure can. There's a great study that looked at the accuracy of assessments in pain for ICU patients, use docs, nurses, family members, and patients who were actually able to self-report. And actually family members were, not surprisingly, probably the best people. They were the most accurate in terms of detecting whether or not the patient was having pain. So it's... they are very helpful in terms of they know the patient best. I know we think there are patients, but they're really their family members. They can help you interpret some of those behaviors and having that data can help you make some... can help the staff make more decisions regarding the findings when they're doing the BPS or the CPOT or numeric rating scale. So it's really important to bring those family members in. And I know the challenges of the family members and we'll talk about that in our question and answer session when it comes to they're having pain, they're having pain, they're having pain. When the patient is unable, so you have your patient on neuromuscular blockade, they can't report having pain, they're not going to give you any behavioral pain assessment, what should you do? Assume pain is present. I find it shocking, but I've talked to people that do still use neuromuscular blockades and every now and then they forget the order for the pain medicine, right? They'll run the sedation, hopefully. They'll run the sedation, but they'll forget that to treat the patient's pain as well. So it's okay to assume pain present in those patients that you know are undergoing painful procedures and can't tell you or if they have reason to have pain. I mean an endotracheal tube itself has been consistently reported as a very painful experience and think of all the lines and tubes that they have in them. So the assume pain present is consistent. Vital signs, that's a tricky one, right? We've been taught for years about, you know, using vital signs as a way of assessing patient's pain and I don't know why we didn't think about it 10, 20 years ago when I was, you know, in that CICU trauma unit, but they shouldn't be used alone to assess pain. They're used as a clue that you should do further assessment, right? Because we know these patients are sick. A lot of them are septic or hypotensive. There's a lot of things that would be affecting their vital signs. Pain could be one of them, but there's probably 99 other things. Oh, that's a good... I have to remember that slogan. 99 problems, but pain ain't one of them, right? Somebody think of that slogan. That might be a great teaching point, right? So they probably have 99 other reasons for these alterations in vital signs. You can use them as, you know, a key to start further investigation, but don't use them alone in terms of vital signs. Okay, you're going to have a whole lecture on the C in terms of choice of analgesia and sedation. The PATI's guidelines give some very clear recommendations or some very clear suggestions and recommendations regarding pharmacologic management. The last PAG guidelines didn't have that, remember? Or was it the PAG guidelines before that? But they do touch upon the effectiveness and which meds should be used for pain or not. You have a whole lecture on that, but I put it in this slide as teaching points if people ask you in terms of what medications are good. You see the green, green, yellow, red. Good teaching strategy. They're available for you to look at and also when you're reviewing your pain management policies, right? To make sure they're consistent with what evidence we have available. Interestingly, and I'm so happy about this, the new PAG... I'm going to get back to the slide one second... but the new PAG guidelines also did an assessment of non-pharmacologic interventions for pain. Any old-school nurses in here that gave back rubs, remember? In addition to the nice tight sheets... I was the worst ICU nurse in terms of you didn't want to pick up my patient. They'd be alive, but they'd be out of bed a mess and the room would be a mess. But, you know, in addition to those nice clean sheets, we used to do like a little bit of the back rubs right before. Anyway, we're getting more and more attention in terms of the potential benefits of doing some non-pharmacologic interventions. If you were laying on your back in an ICU for seven days, wouldn't you want a back rub? 20% off if you go over there since you're at the convention right now, right? So they did and that's in here as well. Talk about some interventions that we can look at that have been shown to suggest some effectiveness for pain management during the ICU. We're doing this really cool study at Wexner Medical Center right now where we're doing Reiki. Kind of wacky, right? I don't believe in it, but I'm the scientist and I have my Reiki person that believes in it. We're doing a small pilot randomized control trial looking at the effects of Reiki for mechanically ventilated patients. Could it help with pain, sedation, anything like that? So more and more attention. Kind of going back to the old school with some of these things. Someone brought up an analgesic first approach before. I don't remember, was it you? Highly emphasizing the PAD guidelines again. Some of your teaching should probably surround some of these terms. It took me a year to say analogous sedation. I was always Angelo. But a lot of the staff that you work with might not be familiar with some of the terms that people are using in practice now. But talking about that analgesia first approach, right? Using an analgesic before a sedative or an analgesia base sedation. I think that's more what you were talking about, right? Using an analgesic or an opioid in particular instead of a sedative, right? So getting the sedative effects because opioids, if you give somebody enough opioids we know they get sleepy, right? And the multimodal approach, heavily emphasized. So using those non-pharm, pharmacologic, non-opioids, opioids. Taking a multimodal approach to analgesia because we really do want to... Opioids are still the main state of treatment for acute pain, alright? But we know that all the issues that we're having in today's society in terms of our opioid crisis, that we really want to minimize the amount of opioids patients receive in the ICU if possible. Great resources in here and in the PAD guidelines for your staff to use when you go back and do some of this teaching. Protocols. Really super important. Ton and ton and ton. Don't go back and rewrite your protocols. Everything that you could think of has been done. Everything you could think of related to pain, agitation, delirium, sleep still kind of out there, there's a protocol for it. Not just one. There's probably 3,000 protocols right now. When I was at Penn we did something called the FAD campaign before the PAD campaign. It was falls, agitation, and delirium. We wrote that 15-20 years ago. Go to people that you trust, look at their... ask for copies. They're not confidential. Look for copies of policies and procedures and pick the ones you like and works best for your institution-specific culture. So here's some of the the non-pharm interventions that the PAD guidelines refer to. So the ones that they're recommending that have some evidence behind them is the massage, music. Anybody using music in their ICUs? There's actually quite a bit of evidence out there supporting. Has to be patient selected music, teaching point. So you know you can't just go into an 85 year old woman's room and put on you know hip-hop or rap or whatever's cool these days. You know it has to be music that the patient prefers. Patient selected, right? Not what we find calming because you know if somebody puts on classical music that might irritate the heck out of an 18 year old trauma victim, right? So patient selected, just keep that in the back of your mind. Use of ice packs, cold, has been effective particularly with obviously like fractures and things like that over the years but we've kind of forgotten about it, right? Relaxation techniques. So again that multimodal approach. Some teaching considerations. I'm done talking. We'll have questions and answers but these are the questions you're going to get, right? All the time that you probably already had. So what do we do with our chronic pain patients, right? Well patients with chronic pain have adapted their response to pain. It's true. They don't look like normal patients, right? They've been dealing with pain for many years. Maybe have been taking opioids for decades. High, high, high dose opioids that again might have fallen off our MAR when they were admitted but they don't necessarily look like they don't have the same behaviors as other people do. So that is true. A lot of times when the patients have psychological dependence on opioids and they're coming into us they also have physical dependence. So we really do want to keep in mind the effects of withdrawal syndrome, right? We have a really neat paper coming out with some great researchers from Puerto Rico. It should be published in a couple months but we don't really have a great withdrawal tool that we can use. Do you guys actively assess for a withdrawal syndrome in the ICU? We need a tool for that. The other thing, how stupid is this? This is one of the things that has urged me since I started this. Why do we give sedatives? What is the reason a nurse will tell you she's given a sedative? Well, okay, so yeah. Safety, comfort. Normally, I think they, I mean, I think the excuse that I was given if I was really trying to do charting and asked why I was given a sedative, they were anxious, right? Don't we use sedatives for anxiety and agitation? We don't monitor for anxiety, do we? Why? It's a thermometer, just like the pain one. Show me where you are in your anxiety level before you give a sedative. I don't know how I got on that topic. But the psychological, physical dependence, need to avoid the withdrawal syndrome, it could happen. You know, I had a neighbor, God bless her heart, who had a two-year-old baby who had RSV, went to bed, woke up the next day, and has been on ECMO for the last 56 days. RSV. She put a tag on Facebook. Oh my god, my heart broke. She put a tag on Facebook that it was the first time she was able to hold her baby. 54 days. 54 days before that mother of this critically ill child was able to hold her child. You guys got chills? Look, I literally have chills. Like, so we're working on the peach, people, to get some of this stuff in here, too. But it shouldn't go that long without 54 days, even if it's, I mean, even if it's that sick of a person when we have people up and walking. But we do need to avoid withdrawal syndrome. The patients are coming in already with a problem. Some of them are on prolonged opioids while they're with us. It is something that we need to work on monitoring, getting a better tool for that kind of stuff. So you do want to have that hat on about who could potentially going through withdrawal syndrome and then maybe we're... they're actually experiencing this and we're calling it delirium. Very difficult to say which is which, right? But to keep that in mind. Older persons, my passion, they also don't present with pain the same way. Youngsters, you know, our teenagers and our young adults, I'm like... I go for colonoscopy. I probably get two bottles of propofol. I can't take pain at all. But our older patients, again, live with a lot of chronic pain, don't present pain the same way. So another special population you need to consider when you're doing some of your protocol developments to keep that in mind. Frequency of assessments, that's still a great question. How often we should be doing that? I think while we know what assessment tools, that frequency is an important question. Developing those policy and procedural manuals with the evidence that you have here in mind. Using those rounding scripts, right? Going to be very important, bringing up that A through F approach, because the A comes up first. What are we doing for the pain? Can we get them off the opioid? Can we use some Tylenol? Hey doctor, you have a second? He needs a massage. Can you go in there and just like rub his back for a little bit? Maybe that'll help with the opioids. So moving those things into practice. The JACO thing, as we mentioned a couple times, is big and it's kind of scary what they're proposing right now. I don't know if you guys have had time to review some of the issues. There seems to be... we have great leaders working on their issue. There's concern about these PRN orders that we're using in ICUs. Right now their greatest attention is around vasoactive medications, but they want orders written in a very specific way. So when you're doing these PRN orders, and I'll show you an example of them, please make sure they're JACO specific, right? But they're changing right now. So you might want to wait like a month because the new finalized JACO, they just had the comments released. A lot of people are up in arms because it's restricting nursing judgment, right? In a way, the criticism is that, you know, we're doing all this documentation rather than practice and not letting us trust our judgment in terms of what these medications... how we can titrate these medications. But they're very specific in how they need to order them. Again, there's examples everywhere. Joanne Stallings probably has great examples for you as well in terms of how they can be written to comply with those regulations. Trying to think of other teaching considerations. Great articles in terms of all of the challenges that you guys were experiencing with some potential solutions that we've tried to offer. Two of them, one here, common challenges and then also implementing the bundle. Things that we've learned over the course of the collaborative. There is a part on there regarding the JACO management and some other additional questions regarding pain. Done. These are the slides that you'll use. Questions about the slides. Questions about pain management. We still have some providers who do order it to the sedation level as a titration parameter and we have made suggestions. So the opioids are titrating to the sedation score? Sometimes and sometimes what they will say is when you say to them can we titrate this to the CPAT level because the sedative is supposed to titrate to the sedation level and is well I'm using it for sedation. So it becomes kind of a difficult conversation to have. That's it. That's a very interesting... go ahead... but that's a very interesting point because if you're using it as a sedative shouldn't the assessment be on then the sedation level, right? Not the pain. Correct. Correct. That's what I was actually gonna say. We actually just got cited recently and I reached out to 16 institutions and nobody else has heard of the citation from what I've gathered except for one other VA in Charleston, South Carolina. We were told that we can't have two drugs on board and titrate to the rest. We had to have specific instructions on which one goes up first and which one comes off first and if it's, you know, not effective in 15 minutes should they call a provider and get advice on what to do next. So it's really become a problem. If anybody has any advice. So the specific citation was for what? It was because you can't have... that you had two drugs going at once? So for this patient, I will say that we're not really up-to-date on sedation and we actually have the patient on propofol and Versed. We do it a lot at our institution and the two drugs are being titrated to a rest and Jaco said that's nursing prescribing at that point. Mm-hmm. So they came back and said that we can't do that anymore, that our orders need to explicitly say that you go up on propofol first and then when you get to this dose and you start the second and then in 15 minutes it's not effective when re-evaluated, then they reach out for advice on what to do next. So every time a drug is moved in a titration, regardless of frequency or dose, it has to be specified by the provider. I could kind of see what they were saying there, right? Because you had the propofol and the Versed both intended for sedation, I assume, right? Yeah. So what I've actually addressed this and where I've been is I will actually write orders. I'll start fentanyl usually when I first intubate them and we'll talk about titration to pain control. But if they're, how do I write, if RAS score is not achieved at zero, then add sedation at that time. One of the problems I've always had with with PAD as a designation though is I wish A was anxiety, not agitation. I tried to fall on that sword. I did. It shouldn't be agitation. It's not, it's anxiety. Right, because the medication you're using is anxiety. It's absolutely right. The other upside though is back in the day when, you know, in Crest, he was referring to Crest, that was when we didn't have Presidex. So arguably Presidex is a extubatable drug and assist in sleep-wake cycles, all those things. So that does change things. But what I have tried to get my nursing to do is still use pain primarily. That's the primary goal. If they are then calm with a zero RAS score, we're good. There's no reason to use the sedation at all. But are your nurses charting pain scales or are they charting the sedation scales? Both. I mean they need to do, they should be doing both, right? Because the assessment, that's where we were just talking about some of the algorithms out there and Duke has a really wonderful, I don't know if anyone's ever seen their algorithm and how they have it drawn out. But that's kind of how it is. I mean an endotracheal tube is one of the most painful things any person can have. Talk to an anesthesiologist about that. I mean if, that's why a person can be just on PRN fentanyl boluses and be sitting there reading a paper, watching TV, changing the channel with a tube in their throat. And they don't need any kind of sedation whatsoever. That's why the anxiety component I think is is key. The wording should be what's their pain, what's their anxiety. If they declare anxiety, that's when your sedation, that's your RAS score. Because the benzodiazepines are meant to treat the anxiety. Well and theoretically, if your pain's controlled, you'll never need your sedation. Yeah, agreed. So we have our orders written like that. We have electronic orders. We have EPIC as our EMR. And so we have do this first, fentanyl boluses. If this doesn't work after X number of doses, go to this. And then within each drug, you have to pick what you want your targets to be. So is it pain or is it sedation? So it's either a RAS or a pain scale within there. And we also learned very early on that if you don't pre-pick things for people, they'll default to something you don't want them to. So we pre-check boxes. So you have to actually uncheck them if you want something different. So like negative 4 for a RAS. So ours is defaulted to 0. So we have physicians that go in and pick negative 4, but that's active. It's not a passive. Because again, if you have lots of trainees, there's no possible way you can keep up. So you have to have some way to standardize practice. And that's how when we first did the ABCDE bundle at the Nebraska Medical Center, we did the opt-out method, right? So everybody got the ABCDE bundle unless the physician went in and opted out for that patient to make it more active. So just along these lines, and maybe this is a... I don't know if this is a stupid question. I hope not, but if it is. So I think we have traditionally had our nurses assessing their sedation scale on every patient. Are we... would it be a standard that you guys would suggest to just to do it continually or stop it if you're not using a continuous drug? That's an excellent question. Not stupid at all. Some people have even asked if you should do it on non-mechanically ventilated patients. Of course. We do. And the reason I ask that question is it becomes really difficult to audit it because when you look at it as... we have a lot of patients who, you know, they may have some encephalopathy from a disease process. They've maybe been off sedation forever or maybe never on it and their RAS is being recorded as minus 3, minus 4, minus 5, for whatever reason because they're that sick and they're dying. And I personally, as a someone who audits these charts, I have a really hard time figuring out if the nurse is actually in the range and, you know, because a lot of times you're flipping back and forth between 10 different screens in the EHR to figure out what the patient's actually on at the time and whether or not they're really... I know at the bedside in rounds on that day it's probably discussed and it's fine, but I think from a purpose of determining whether we're being compliant as a whole, I could use some suggestions. I think that's a great point. I think keeping it up for vent, non-vent, to keep it up at a frequency that you think is, you know, appropriate for that institution. It's going to be told what that frequency should be if you're doing a JCO, if you're using meds, right? There's going to be some evidence behind what time frame you chose to for the documentation. But the most important thing that I'm hearing throughout here is we rely on a lot about that documentation for the RAS, but if you... my challenge for you is to go back to your institutions and go and look at all the RAS of zeros that you have and go in and see what RAS they are. There has to be a lot of teaching around not only the pain scales, but the level of arousal scales, because it's very inconsistently recorded. Everybody's like a minus one, minus two. You go in there, you're doing your sternal rub, and they're still not moving, but they're a minus one, minus two. So there has to be education involved, but that education also has to include audit and feedback and direct teaching. So going, checking off the nurses that they know how to use the RAS, right? The level of arousal, and that they're right. So doing some kind of spot audits. Brenda wrote that paper years ago, I think it was about delirium. But there's still... there remains a lot of inconsistency regarding what people are calling a minus one. And literally the concept of looking at RAS as an arousal scale versus a sedation, even though it's called Richmond sedation, but looking at it as an assessment of arousal versus how much sedation, and then it can apply across the board. Hi, a little different question. Can you go back to the operational definitions of your assessments, and then what you considered to be clinically significant pain? And then not only what those were, but how did you obtain them for that? So for the collaborative, do you mean? Yes. Yeah, okay. So for the collaborative, we defined check yes, you did the A. If you got sick, if you had greater than six, greater than six a day. So it's that every four hours. I wanted every two. So management wasn't included in that, like whether they had clinically significant pain or not? Correct. What we wanted, the performance of the assessment to be the major outcome, right, for this particular piece, for the analysis. No pain outcome, though. We did follow pain. So we follow... so we have results on how many patients had significant pain episodes. Yes. The definition, you're right, and your nurses will need to know that, or doctors and the whole team, will need to know what the definition of significant pain is for the CPOT and BPS. Does that make sense? So we define, yes, you did the A right if you got six or more pain assessments a day. And was clinically significant pain one assessment per day that was greater than whatever? Is that what your definition was? Yes. Brenda, you could... is Brenda still here? I think it was if they had a significant pain episode once in that 24-hour period. Is that correct? That was significant pain. Defined by CPOT, numeric rating scale, blah, blah, blah. A lot of people were non-compliant because they decided not to use any of those tools, so they didn't do the A ever, right? We did six months retrospective chart review and then during the implementation phase it was all prospective. This is fantastic. I'm looking for some insight on two sort of very similar issues, which is confounding. When we go through our chart reviews, one of the challenges, one of the benefits is we have a really good research team involving nurses and pharmacists and so on, but when I go through the data, I find a direct clinical correlation between RAS and our delirium scoring because it seems that we're missing hypoactive delirium and really we're diagnosing delirium as just those pain-in-the-ass patients, the agitated ones, frankly. The moment a patient is calm, the delirium scores drop, and if it's hypoactive delirium, the delirium scores are low. We're not capturing hypoactives and that sort of really is shifting our ability to assess RAS. The second thing is about a quarter of our patients have chronic pain and when they actually express pain, it's not actually pain, it's distress, whether it be anxiety. So we're just getting this tremendous amount of confounding and trying to separate these two things out. And I mean, Prosodex has been a bit of a miracle drug. I think somebody else pointed that out because it addresses both pain and anxiety, but how do you in this process try to reinforce and tease out those two big confounders that the chronic pain folks are expressing anxiety and are as pain and our folks who are hypoactively delirious may not be expressing pain but are actually having it and we're only looking for the agitation. So excellent comments and the D-lecture will specifically get to that issue. More often than not, the CAM-ICU is being administered incorrectly, meaning you will actually, in some way, depending on how you define it, be able to tell whether that patient was hypoactive, had hypoactive or hyperactive delirium because that's all based on the RAS score, right? So 10 to 1, your CAM-ICUs are wrong. You're getting a lot of unable to assess, unable to assess, unable to assess which are useless. Oh, I always forget about that one. Yeah, but you can't. You're Canadian. You're stuck with it. The beauty of having a multidisciplinary research team with pharmacists and nurses and so on is that change is much easier because we have the buy-in. Those stories come back through the qualitative research. So I can't switch it, but I won't go through that effort if CAM is going to be better. It seemed to be better in the last course. You will be able to get hypo-hyperactive delirium if the nurses are doing the CAM-ICU right because dependent on that CAM-ICU, you have to do a RAS, right? That you have to do a level of arousal assessment and you're assessing arousal. Are they sleepy? Are they normal? Are they hyper? So you'll, from your data, if the both are done right, you'll be able to have that number. In terms of the chronic pain patients expressing that, absolutely. That's why we need to have them awake and that's why we need to have... there's anxiety... there are anxiety scales just like that. So I want to make a comment to echo what you're saying, Michelle. With the CAM-ICU, the unable to assess, you really need to do interrelated reliability to ensure and we actually collected data on our percent unable to assess and then married and looked at how many unable to assess had a RAS of minus 3 or minus 2 because they should be able to be assessed. Then we're able to target those nurses and providers that were doing it incorrectly. Then continue to measure the percent of unable to assess or the percent where we did it incorrectly. We had a RAS of a minus 3 or above and it was unable to assess. So it's a real important one and then the other thing, and this will come up in the delirium lecture, is that people will ask the patient to just follow commands and then assume that that is they're not delirious. So it's ensuring that they're going through all the steps and talking about that on rounds, etc. Word out for palliative care consults too. Did you read the JAMA paper, Wes? Yeah. When was that published? Last month. Jackie's paper? The ABCDF bundle at the end of life. Did you guys see that yet? It's published in JAMA Open Network. Oh, is it that one? So we looked at the bundle use in those patients that might be at the end of life use and kind of got a snapshot of that nationally as well. But yes, palliative care is something we underutilize in the intensive care unit. Palliative care consults for chronic pain patients? Duh, right? I mean they're the patients that we should be doing it for. That's not our expertise and hopefully a palliative care person is not going to come in and do your vent thing, right? So a great resource would be a palliative care consult in those really complex patients so we don't screw them up even more, right? I mean that's not our expertise. Well this could be very long, I guess, but my question quickly just to build on what was said before is when you have the thresholds for the BPS, right, and it's significant, but is that statistical significance or clinical significance? Then if that really differentiated those scores, the distress and the pain, because if they didn't then they propagate the kind of confounding. So the scores that I gave you when you're doing this teaching has nothing to do with statistics at all. So they're the scores that when they went back and did correlations, asked a patient, did the BPS or things like or compared different patients to that, those were the numbers that seemed to indicate significant pain, meaning really bad pain. Pain that needs to be treated maybe is a better term than using significant. So they're the numbers that that pain is something that should be addressed. Does that make sense? Yes. It has nothing to do with statistically significant, but significant enough that we should intervene. And intervene with a minimum of something? Yes, more likely an opioid. Not give Tylenol, but give... You could try Tylenol first, right? Treat with anything. Yes. And it's hard again because you cannot use, and that's a teaching point, you cannot use the scales as kind of, oh we went from an eight to a six to a two or back to a six. You can't use the tools that way. They're more of a yes-no. Our goal is like get them off the sedation so we could ask them what their pain is because they're not like, I don't know what the proper term is, but like that they're not scale. And that's why so many people are having issues with the JCOs because it's very difficult to... those numbers on there are your important numbers. They're the treat the pain numbers.

ICU pain assessment

evidence-based practice

ABCDE bundle certification

chronic pain

hypoactive delirium

subjective pain assessments

non-pharmacologic interventions

sedation and opioids

standardized protocols