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☆
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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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.