QI Project Reduces Severe Pain and Serious Adverse Events: A Systems Approach to Patient Safety
ABSTRACT & COMMENTARY
By Linda L. Chlan, RN, PhD
Dean’s Distinguished Professor of Symptom Management Research, The Ohio State University, College of Nursing
Dr. Chlan reports that she receives grant/research support from the National Institutes of Health.
This article originally appeared in the September 2013 issue of Critical Care Alert. It was edited by David J. Pierson, MD, and peer reviewed by William Thompson, MD. Dr. Pierson is Professor Emeritus, Pulmonary and Critical Care Medicine, University of Washington, Seattle, and Dr. Thompson is Associate Professor of Medicine, University of Washington, Seattle. Drs. Pierson and Thompson report no financial relationships relevant to this field of study.
Despite the intensity and frequency of pain during common nursing care activities such as turning and repositioning, patients rarely receive premedication prior to these procedures. Pain can induce a stress response in these patients that can lead to serious adverse events (SAE). Documentation of SAEs impacting care quality is poorly understood. To address these care quality gaps, a systems approach by a multidisciplinary French ICU team was used to improve patient safety and quality of care through addressing pain management and adverse events when routine nursing cares were performed. The Plan-Do-Check-Adjust method was used to guide this quality improvement (QI) project. Each phase of the project lasted 1 month, separated by a 4-6 month interstudy phase, for a total project period of 20 months. SAEs were defined as cardiac arrest, new arrhythmia event, and clinically relevant changes in heart rate (tachycardia or bradycardia), blood pressure (hypotension or hypertension), oxygen desaturation, bradypnea, and ventilatory distress.
The QI project began with a questionnaire completed by nurses to assess their knowledge of sedation and analgesia guidelines and any associated challenges with these guidelines. Educational interventions were developed based on these responses, and included posters and face-to-face scheduled classes for all nursing and medical staff. The education consisted of pain assessment (numeric rating scale or behavioral pain scale) prior to any patient movement interventions, analgesic drug therapy, and instituting non-pharmacological interventions such as music in every patient room. Every day between 6 a.m. and 8 a.m., every patient turning was evaluated to measure the impact of the educational intervention on the pain level and physiological indicators of the stress response. Next, a 6-month period of adjusting the medical and nursing care strategies was undertaken. During this time, physicians wrote orders for one or more analgesic medications to be given before the morning nursing care procedures. Following this 6-month period, nursing care activities every day between 6 a.m. and 8 a.m. were evaluated to determine the impact of the care strategies adjustments made previously.
During the evaluation phase of this QI project, pain was assessed by the nurse prior to and during any care movement interventions. SAEs to assess for indicators of the acute stress response to these movement interventions were measured by physiological parameters. Provision of pharmacological and non-pharmacological therapies was recorded on a flow sheet. Evaluation of the educational interventions revealed that the incidence of severe pain and at least one SAE decreased over the project period, while analgesia administered prior to morning nursing care procedures increased. The incidence of SAEs was observed to decrease except with intubated patients and those with severe pain. This finding highlights the complicated nature of managing mechanically ventilated ICU patients. Unfortunately, the use of music over the project period was not consistently implemented, which may suggest a need for further education and practice implementing this integrative therapy.
Routine nursing care activities can induce or exacerbate pain, which can lead to a heightened stress response and include any number of adverse events in critically ill patients. Pain is a common experience in critically ill patients for which analgesic medications are frequently administered. However, as the authors point out, moving and other routine nursing care interventions are not perceived by clinicians to be painful. These data suggest otherwise. A number of patients experienced moderate-to-severe pain while receiving necessary routine nursing care such as bathing, turning, or linen changes. Over the course of 20 months, the QI project developed and evaluated demonstrated decreased severe pain and a change in practice to administer analgesic agents early in the day prior to movement-based care activities.
This well-described QI project is the third such project conducted by this multidisciplinary group. This group of clinicians is experienced in doing a quality project and they are well aware of the various pitfalls and challenges associated with implementing changes in practice. This paper by de Jong and colleagues can offer the QI novice a road map for how to conduct such important clinical practice change projects to improve care quality in the ICU.