Within two critical care units, there was a need identified to formalize a process to improve sleep, optimize pain control overnight, and minimize disturbances as individualized to each patient.
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Caring-Centric Implementation of Sleep & Pain Initiatives
1. Kaiser Permanente, Northern California
Caritas Consortium 2013
Caring-centric Implementation of Sleep & Pain Initiatives
Caritas in Action
How Caring Science informs and inspires KP caregivers and affirms our commitment to provide our
patients and their families exceptional care
2. Caring-Centric Implementation of Sleep & Pain Initiatives
Intent to Contribute Statement:
Description of Units - Two 16 bed critical care units, one medical and cardiology
focuses, one cardiovascular surgical.
Problem Identified - It was noted by the nursing and physician teams that we often had
patients in our critical care department that:
1.
Awaiting room availability on the Med/Surg unit (no longer required critical care level monitoring)
2.
Needed closer monitoring overnight after a cardiac catheterization procedure.
3.
Needed closer monitoring overnight after a minimally invasive vascular surgery (i.e. Carotid
endartarectomy).
Concern - Our culture in the critical care departments and standard of care did not allow
for optimizing sleep in the above mentioned patient populations. There was a need
identified to formalize a process to improve sleep, optimize pain control overnight, and
minimize disturbances as individualized to each patient.
3. Caring-Centric Implementation of Sleep & Pain Initiatives
…Continued
Implementation Process 1. Sleep protocol- Created by Gina de la Fuente, SN III in CVICU
a. Protocol developed by Staff RN. Printed up and laminated - Posted at the door of each patient
when the protocol was deemed appropriate for the patient.
b. Intensivists created a dot phrase to quickly order the protocol under nursing communication
orders.
c. This is truly a nurse-driven protocol.
2.Painscape initiative- started at the beginning of 2013.
a. Focused on key behaviors- Staff were asked to include these practices in the care and handoff.
i. Preparing and Centering before entering the patient room.
ii. Probe the pain scale responses- Really discussing with the patient their needs.
iii. Use the most appropriate dose for initial transition to PO pain medication.
iv. Reassess on a timely basis
v. Encourage around the clock dosing
vi. Work as a team to keep pain regimen going at night.
b. Evening and Night Shift focuses involved the patient in the planning for pain controli. Ensuring they know what they can have for pain medication and at what time.
ii. Working with the patient to decide when they should be woken up for their medication.
4. Caring-Centric Implementation of Sleep & Pain Initiatives
…Continued
Caritas Processes Addressed • Developing and sustaining a helping-trusting authentic caring relationship.
• Creates a healing environment at all levels whereby
wholeness, beauty, comfort, dignity, and peace are potentiated
• Reverently and respectfully assisting with basic needs, with an intentional caring
consciousness, administering “human care essentials”, which potentiate alignment of
mind-body-spirit, wholeness and unity of being in all aspects of care.
Measurement - We will utilize our HCAPS- Survey Scores for critical care departments
as well as provide a specific patient case scenario that demonstrated how
implementation of these protocols improved care.
5. Caring-Centric Implementation of Sleep & Pain Initiatives
Inspired Contributor(s) 1 :
Kristie Hills
Identifier
Consortium2013-July, San
Francisco, Podium, Patient Care
Services
Kelly Timothy
-----Service Area: San Francisco
Medical Center: SFO
Pain Management, Quiet/Sleep,
Workflow, Care Board/Plan
-----Year Shared: 2013
Venue: Caritas Consortium
(separate files)
ID #: n/a
1
Hospital Initiatives, Healing
Environments, Team,
Patients/Families
Descriptor
Affiliation: PCS
Format: PowerPoint
Keyword TAGs:
Names as listed in Lotus Notes, otherwise personal e-mails indicated
7. Why focus on Sleep?
Anxiety &
Lack
of
REM
sleep
Impaired
Cognition
Insulin
Resistance
Elevated
BP and
HR
Release of
Stress
Hormones
Release of
Inflammatory
Cytokines
Delirium
Stress &
Pain
Intolerance
Daytime
Fatigue
*Hardin, K. (2009) Sleep in ICU: Potential mechanisms and clinical implications. CHEST, 136, 284-294.
*Olson, T. (2012) Delirium in the intensive care unit: Role of the critical care nurse in early detection and
treatment. Dynamics, 23(4), 32-36.
Delay in
healing!
8. Caritas & Sleep Protocol
Reverently and respectfully assisting with
basic needs, with an intentional caring
consciousness, administering “human care
essentials”, which potentiate alignment of
mind-body-spirit, wholeness and unity of
being in all aspects of care.
9. Before Sleep Protocol
• Pt care was organized in the way most
convenient to healthcare staff.
• Common practices included:
Baths on night shift
Every hour round the clock vital signs
X-Rays and labs 0400
Environment not optimal for sleep: Noise & Lights
10. Sleep Protocol Development & Implementation
• RNs and MDs developed a sleep protocol
• Defined pt population the protocol would
pertain to
• Leadership engaged
• Health care team educated regarding
protocol and order set
11. Enhancing the sleeping environment
• Midnight to 6 a.m. is sacred avoid orders for meds,
X-Rays, and labs
• V/S at 0000 and 0600
• Offer sleeping aid if unable to sleep
• Promote a sleeping environment:
Earplugs & eye masks
Close the door and blinds
Turn down alarms
Quiet outside pts rooms
Soothing music in the background offered
12. Where are we with the protocol?
• No formal measure of outcomes, informal
data gathered on pt satisfaction
• RN’s, MD’s, and pts all have positive
feelings about the protocol
• Sleep protocol fully implemented in the
order set
• Shift in focus on promoting sleep for all pts
13. Outcomes
• General culture is changing. Still have work to do.
• Positive feedback from staff and patients related to sleep
protocol.
• Patient satisfaction score trend (Quietness of hospital
environment):
Location Nov Dec
2012 2012
Jan
2013
Feb
2013
Mar
2013
CVICU 40
75
50
60
45.5 25
ICU
40
42.8 100 60
50
Apr
2013
Composite Rate
48.5
33.3 51.43
14. Pain & the Caring Sciences
Untreated /
Undertreated
pain in
hospitals
Harms our
patients
Harms our
relationships
with patients
Harms
ourselves
16. Common practice pre-Painscape
• Limited medication orders
• Limited assessment tools- Numeric & WongBaker faces
• No anticipatory pain order sets
• No plan in place for weaning patients from IV
pain medication
• No plan for pain control while patients slept
• Communication regarding pain management
was not always prioritized at shift handoff
17. Caritas involved in Painscape
• Develop helping – trusting- caring
relationships
• Use creative scientific problem-solving
methods for caring decision making
18. What does it boil down to?
Relationships
Communication
19. Painscape Implementation =
Enhanced communication
• NKE
• ATC pain orders
• Interdisciplinary rounds
• Coordination for anticipatory pain med administration
• Prioritizing pain control in discussion of daily goals with pt.
• Prioritizing reassessment for efficacy
• Transitioning from IV to oral pain meds
• Ensure PRN pain meds are continued through the night
• Utilizing new order sets
20. How we implemented change
• Painscape introduced at Unit Council &
Critical Care Q PIT
• Painscape champions
• New Painscape behaviors introduced at
daily huddle
• Focus on pain during NKE,
interdisciplinary rounds
21. Outcomes
• Goal: Personal experience enhanced with pts
• High scores with patient’s perception “doing everything we
can” to help pts with their pain.
• Patient Satisfaction Score trending (Pain management related
questions):
Location Nov Dec
2012 2012
Jan
2013
Feb
2013
Mar
2013
Apr
2013
80.5 100
Composite Rate
CVICU 80
83.3 100
60
ICU
75
100 85.7 83.3 85.6
83
100
80.7
22. Painscape Reassessment: Where are we and
where are we going?
• Maintain/sustain phase of Painscape
• New pain assessment scales for our confused
and intubated pts
• Goal for HCAHPS scores is 90%- so we still have
work to do!
23. Patient-centered Care to Improve Outcomes:
Pain
&
Sleep
Deprivation
Acute
Physiologic &
Psychological
Changes
Increased
Stress to
Patient
and
Family
Decreased
Patient
Satisfaction
Decreased
Healing
Notas del editor
Presenting on these 2 different interventions because Caring Sciences is a patient-centric nursing theory, and these were 2 very patient centric initiatives recently implemented in our facility. ICU & CVICU are 2 high tech environments- these are 2 low tech, high impact interventions. Sound simple, but providing 2 such basic needs can prove to be quite complex & challenging in our work environment
Lack of REM sleep causing daytime fatigue, stress intolerance, anxiety, Delaying healingUnable to wean pts from vent, impacting early pt mobilization. Also helps prevent delirium. Reference the KPSFO Sleep protocol
Jean Watson’s website references
Expand verbally on these concepts
- RNs and docs in CVICU developed a sleep protocol based off of a regional sleep protocol. Sleep protocol has since become part of a larger order set to prevent delirium- “Delirium Order Set” Population defined. The protocol does not pertain to all pts since some critical care pts will still need interventions throughout the night Balancing pts need to sleep with other care concerns such as correct pt selection, safety, skin care and pain management remain important Introduced to RNs during huddle, ICU and CVICU md’s educated by the MDs that developed the protocol
Discuss the relationship of these interventions with the caritas. These interventions are based on focusing on pt needs- and RN must have a discussion with pt to discover out what’s the best environment for them.(Avoid orders for meds, cxrs, and labs)
- Still meeting challenges with changing work flows: ie radiology coming at a later time for xrays, md’s acceptance with getting data later- General shift in mentalitySleep for all pts important not just those on protocol- sleeps importance for the pts preventing delirium & enhancing general health.
- Pain management is important to providing high quality care and pt satisfaction. It’s harmful to pts- fight or flight response, immunosuppression, myocardial o2 demand. It’s harmful to our caring consciousness, wholeness, authenticityKey aspects of painscape r/t caring sciences is that it is about our changing our attitude/approach as clinicians and about our relationship with the patientMake arrow similar to sleep protocol
Assumption of no pain because pts sleeping.
These things don’t look to pt-centric. It was trying to fit pts into a cookie cutter model that didn’t allow enough room for individualization of care. Numerous issues with the way we are used to managing pain- from such basic things as recognition, communication, and prioritization. We need to get some caring sciences up in here- as well as some research based interventions.We had 1) continuous drips with prn breakthrough, 2) scheduled pain meds or 3) prn pain medication 4) We only had 0-10 scale and the Wong-Baker faces scale5)There was no way to legally chart and administer for anticipatory pain ie prior to pt mobility or prior to a painful dressing change. 6)There was not a good plan in place for weaning pts from iv pain meds to oral meds.7) We did not have pain scales for confused and intubated patients8) No plan for pain control while pts slept. Previously, if pt was sleeping it was considered that they were not in pain, and this sufficed in the charting as well. “Sleeping” was equated with 0 pain.9) Communication regarding pain management was not always prioritized at shift handoff- only addressed if it was a problem
An attempt for a pt-centric approach that allows for clinicians to provide individual care and… elaborate using caring science terms here
We need to do a better job managing pts pain, the way to do this involves many minor tweaks, but in reality it boils down to better communication, and establishing & maintaining relationships.Pt to RN, RN to RN, Involving MD’s & pharmacy
Communication piece: It’s all about enhanced communication1) Ensuring a good handoff communication regarding how pts pain has been kept under control2) Ensuring pts with continuous pain are ordered for scheduled round-the-clock dosing rather than prn’s.3) Discussing pain management during interdisciplinary rounds with team4) Coordinating with PT/RT and wound RN for when anticipatory pain meds are needed5) Prioritizing pain control as a goal to discuss during beginning of shift when discussing daily goals 6) Prioritizing reassessment to ensure pts pain control needs are being met7) Utilizing highest safe dose of oral pain meds when transitioning to iv- trust with pt and with care8) Making sure prn pain meds are continued through the night so pts don’t wake up with 10/10 pain because they slept through a prn dosage (this is where the reassessment element is missed, not only at noc but during any shift)9) New pain management order sets developed and are now being used for: opiate naïve vs opiate tolerant, shorter dosing intervals to titrate to pts need, anticipatory prn pain med orders,
MDs aware at Quality Performance Improvement Team. Pharmacy informed through their leadership. Pain scape Introduced at our Unit Council- RN’s at unit council educated on pain scapePain scape champions selected to promote behaviors on the unit- Put up bulletin boards on the unitNew painscape behaviors introduced during huddlesNew focus on pain NKE, discussion of pain on pt rounds, communication across disciplinesGetting over the notion that this is more work- it’s not more- it’s just assessing pain more effectively and in the end, if your pts are comfortable it will most likely be less work.
It’s difficult to ascertain our success with our data from HCAHPS, because we don’t d/c from ICU often, so our sample size is usually 1-3 people. Kristi- do we have more data???? HCAHPS data suggests that prior to painscape we were pretty successful and continue to do well with “doing everything we can to help pts with their pain.” We vary month to month on pts perception on how well we’re controlling their pain, but the trend over the last year is positiveWe have made significant improvement with how well pts perceive that we are teaching them about the pain scale and how we are planning to manage pain.Over the last 6 months of 2012 the ICU scored 100% on how well pts perceived the md’s treated their pain.
All aspects of painscape have been implemented We are now in the maintain/sustain phase of Painscape- there is a pain scape board that not only includes info on what it is and why we’re doing it, but that also shows data specific to our unit regarding pts pain experience pre and pose painscape New pain assessment scales have been implemented that make it easier to assess pain for our confused and intubated pts. These were introduced during our annual skills day this year in May-June. Pain assessment tool from painscapeincludes:faces, thermometer, numbers, and descriptions of pain (for mild, mod, severe etc.). Lots of assessment tools- we RN’s just need to choose what will work best for us. Kaiser’s goal is to reach 90% with HCAHHPS scores on the elements regarding pain, so we still have work to do.