Well, welcome to this presentation. I have the honor of talking to you about resuscitating the letter A, so the assessment prevention and management of pain. As Dr. Barr mentioned, the challenges that we're facing in the ICU right now are very real, impacting everyday care, in particular the challenges that we're having with nurse staffing and the influx of new graduates that we have in our ICU, the use of travelers and inconsistent staff. One of those challenges will be getting everybody reinvigorated to follow the ABCDF bundle as best they can, but most importantly, really focusing back on the basics of what we know works. So for the next 10 minutes, not to ruin the surprise, but what I'm going to emphasize with you is what we know that works. So the previous versions of the ICU liberation guidelines and the A3F bundle publications that we have, the knowledge that we developed over the last 10 years, really bringing you that evidence so that you can then distribute to the colleagues that you work with and your institutions. So when we're talking about the letter A, we are referring to the assessment prevention and management of pain. And when we do that, the first step is assessing pain. For the assessment to be good, we all have to come to the common agreement that the gold standard of pain assessment is still the patient's self-report. Pain is truly a subjective experience, and I know many of my colleagues would love to have some kind of objective or omic approach to measuring pain. Right now we don't have that ability. Hopefully maybe in the future we will. But again, pain is what the patient tells us it is. So when we're assessing for pain, one of the things that we really do want to remember, and it's been tough over the last few years with the COVID-19 challenges, is really engaging our family members. Now that some of our hospitals are letting them back at the bedside, really engaging them in assessing pain. They again are the gatekeepers and most knowledgeable about the patients and can give us some hints into what the patient presented like beforehand when they were having pain. The guidelines suggest in the ABCDF bundle as operationalized how often we should do these pain assessments. And the suggestion is that we're doing them at least six pain assessments per day using a valid, reliable tool. And nothing new here has changed. Again, we're going to be focused on using that numeric pain rating scale for the patients to give us their interpretation of their pain levels. But for those patients that are unable to give us that numeric value, we're going to be using tools like the behavioral pain observation tool and the CPAP, the critical care pain observation tool. The ICU liberation website on the SCCM has these resources available for you that you can take back for when you're doing some of this education surrounding effective use of these tools. But nothing has changed in terms of the way that we're going to be assessing patients' pain level. One of the other great teaching points that we like to emphasize is that it's really important to recognize that pain is common with even routine procedures in the ICU. So obviously we think of those really super painful procedures that our patients go through, the chest tube insertions, the A-line insertions, Foley catheters, things like that. But for many critically ill older adults, even the simplest nursing procedures, for example, turning on the side or repositioning that we do so frequently to prevent the pressure ulcers, that pain is a real occurrence even with those common procedures. So when we're thinking about treating, preventing, and managing pain, it's really important to kind of put on your detective hat and really think about if we need to premedicate patients for even some of those common daily procedures. And of course, we always want to treat pain first. So before we reach for our arsenal of sedative medications, really treating the patient's pain adequately before we use those sedatives. There are a bunch of non-pharmacologic interventions. The current guidelines suggest offering critically ill older adults things like massage. That'd be great, right? Good old days when we had that opportunity to give our patients a massage during their baths and things like that. Music therapy to relieve non-procedural and procedural pain. That music therapy, again, being reflective of what the patient likes. Even though we might like hip hop or rock or something like that, for the pain and anxiety relief, it's really important to make sure that the patient identifies what type of music is most relaxing to them. Using things like cold therapy and other relaxation techniques and various other therapies like Reike, pet therapy, family presence, even if they're not strongly supported with randomized control trials, some of your ICU colleagues have had really great success with programs that offer these different therapies in the ICU. And making that connection among ICUs is a really great opportunity to learn from others. In terms of pharmacologic interventions, you're going to reiterate that we are still going to do that assessment-driven, protocolized-based approach to pain management. So many of us have our pain protocols operationalized in nursing procedures and other guidelines that you might have at your institution, so kind of dusting off those manuals, make sure they're up-to-date with the recent guidelines, but really taking that protocol-based approach because we know that that works best in terms of pain management. The guidelines suggest that there are some non-opioid strategies that you can consider using in terms of pharmacologic management. Our good old friend Tylenol, they're on the top of the list there. Using these less intense medications to reduce opioid consumption in the critically ill older adults, because then you can avoid some of the common side effects that we have with the opioids that can be equally troublesome for critically older adults and some of the side effects that they might experience. Again, treating neuropathic pain, neuropathic pain medicine for those patients with neuropathic pain and using distractive and techniques like that. As Dr. Barr mentioned, we had some really great evidence that we were making some progress with our ABCDF bundle pre-pandemic, and in fact, the A in the ABCDF bundle was one of those things that we had the most success with the awesome 68 ICUs that worked with our, that participated in the ICU Liberation Collaborative. As you can see in this chart, A was actually the assessment prevention and management of pain was really one of the things that was one of the best performing elements in the bundle. So you see that we were really good with it before the collaborative started and we got even better as time went on during the course of the collaborative. What's interesting and what is kind of an optimistic thing to do is that we also saw some really interesting variability with the element A. So we saw this great variability in terms of delivery of the bundle in general. We had a lot of opportunities for improvement in terms of the complete performance, meaning that patients get every part of the bundle every day like we wish everybody could. But even within the different bundle elements, and in particular in letter A, you can see on this chart that there was a wide variation among ICU practices throughout the nation with the assessment prevention and management of pain. We suspect that some of that variation came down to the use of tools because when we operationalize what it means to be doing the A and A through F bundle, it was the use of those valid and reliable tools. So we think some of the patient, some of the intensive care units may have chosen to use tools that were not guideline recommended. But that's pretty great news. We also just did a follow-up study where we asked practicing ICU clinicians, and if you filled out the survey, fantastic, thank you so much. But now that we are coming through the worst part, hopefully, I shouldn't have said that, probably bring us back, but now that we are trying to reemphasize and reenergize A through F bundle implementation, what are some of the strategies that clinicians that are practicing right now say that we can do to help? And we have a really great idea. Nobody in this room is going to be shocked, but the biggest suggestion being is that we really do need those personnel and equipment resources available to providers in the intensive care unit to make the bundle implementation successful. So with the pain assessment part of it, if we're thinking about personnel, equipment, and resources, again, I think the most logical thing to do at this point is if you're one of those units that really is struggling with a lot of new-to-practice nurses, God bless their soul, we know that those nurses were also educated during the pandemic, and that has been very challenging on them as well, but in terms of the personnel and equipment, now might be a great time to bring out those guidelines to make sure that the tools that we're using are the guideline recommendations, and maybe if you have the time and opportunity to do some of that teaching as it relates, particularly to the behavioral pain scale assessments. We also know that the clinicians right now really are begging, and it's kind of surprising to me, because we've worked with such high performers in the ICU liberation, really invigorated ICUs, but clinicians want really available protocols, so they want those protocols right at their fingertips, so suggesting that the, however your intensive care unit is operationalizing these different bundle components, that they can have access to that, so that they know in a quick way, like nobody wants a half-hour lecture, I'm glad my part's almost done already, these learners really want something touch, this is what I need to do for A, this is what I need to do for B, so they want those protocols and procedures in place, but they want it delivered in a way that's very time-friendly and engaging. And they also, interestingly, are pretty pleased with the amount of collaboration and coordination of care, but we're hearing still that there's some challenges, and again, a lot of those challenges that they're expressing is related to staffing turnover and new staff on the unit. What's interesting, when we looked at strategies to increase the A through F bundle, and even the A bundle, there was some differences that we saw in terms, and this will be published shortly in Critical Care Exploration, but there was some differences in what both different professions thought are what is important ways of getting these elements into practice, and also differences among administration. And interestingly, one of the biggest challenges is the emphasis that clinicians really, truly believe that we do need to have more investment in that manpower to make these processes happen than administrative leaders or the C-suite, so making that connection very important. So again, probably nothing too surprising in terms of what is happening in terms of assessment, prevention, and management pain in the ICU, but that's a really great thing. It gives you the opportunities, because I assume you're all the leaders in here that were involved in the initial efforts to get the bundle into place in your units. Nothing really new has changed as of yet. We're working on the revised updated guidelines now, but it will give you the opportunity to pool all of these great resources that the SCCM has in terms of the bundle and to not reinvent the wheel. I look forward to taking questions afterwards. Thank you.

pain assessment

ICU challenges

evidence-based practices

non-pharmacological interventions

collaboration of care