Caring-Centric Implementation of Sleep & Pain Initiatives


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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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  • 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.
  • Caring-Centric Implementation of Sleep & Pain Initiatives

    1. 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. 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. 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. 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. 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
    6. 6. Sleeping Protocol & Painscape Initiatives
    7. 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. 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. 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. 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. 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. 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. 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. 14. Pain & the Caring Sciences Untreated / Undertreated pain in hospitals Harms our patients Harms our relationships with patients Harms ourselves
    15. 15. Life in the ICU before painscape…
    16. 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. 17. Caritas involved in Painscape • Develop helping – trusting- caring relationships • Use creative scientific problem-solving methods for caring decision making
    18. 18. What does it boil down to? Relationships Communication
    19. 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. 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. 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. 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. 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