Implementing the 2013 PAD Guidelines
Implementing the 2013 PAD Guidelines
The 2013 PAD guidelines emphasize the importance of using nonpharmacological interventions in the prevention and treatment of PAD. The three strong recommendations include preemptive analgesia and/or nonpharmacological interventions (e.g., relaxation) for patients undergoing chest tube removal, early mobilization whenever feasible to reduce the incidence and duration of delirium, and sleep promotion by optimizing the environment, using strategies to control light and noise, clustering patient care activities, and decreasing stimuli at night. Additionally, a weak recommendation suggests preemptive analgesic therapy and/or nonpharmacological interventions may also be administered to alleviate the pain for other (i.e., non-chest tube) types of invasive or potentially painful procedures.
Although not addressed within the guidelines, several additional nonpharmacological interventions that may be beneficial are mentioned within the text. These interventions include the use of music therapy and relaxation techniques as reasonable complementary therapies in pain management, frequent reorientation to reduce anxiety and agitation, and eye patches and earplugs for sleep enhancement. The authors emphasize throughout the text of the guideline that, prior to administration of medications, care should be taken to identify the etiology whenever patients are assessed to have pain, agitation, or delirium. Although determining the cause of PAD may seem like a relatively straightforward process, it is often exceedingly difficult to do in those patients who are unable to effectively communicate their needs (e.g., patients who are receiving mechanical ventilation or are deeply sedated secondary to medications). The inability to communicate needs effectively is associated with feelings of panic, insecurity, stress, anger, worry, and fear, all of which may be misinterpreted by ICU staff as PAD. It is essential that the ICU team provide these patients a way of effectively communicating their needs. Strategies that may help nonverbal ICU patients communicate their needs include obtaining speech language pathology consults, using communication boards, establishing a reliable yes/no signal, lip reading, and providing patients with tools to write their needs.
Several other nonpharmacological strategies have proven successful at reducing the incidence and duration of delirium outside the ICU setting. For example, the often cited interdisciplinary, Hospital Elder Life Program (HELP) has been successful in not only reducing the incidence of delirium in hospitalized older adults but also as an educational resource, improving hospital outcomes (functional decline), providing nursing education, improving retention of nurses, and enhancing satisfaction and quality of care. Interventions used in this program include, but are not limited to, the use of orientation boards, the provision of cognitively stimulating activities at least three times daily, early ambulation, ensuring patients have needed sensory aids (e.g., glasses, hearing aids), nonpharmacological sleep promotion, interdisciplinary rounds and care planning, and oral volume repletion and assistance with feeding. Although not formally studied in the ICU setting, many of these strategies may be helpful.
Although the PAD guidelines suggest that most of the nonpharmacological interventions are "low cost, easy to provide, and safe" this does not mean they will be easy to implement in everyday practice. Team members will need resources and encouragement to make the changes a reality. If the presence of a music therapist or healing touch expert is not possible, ICU team members will benefit from education and guidance on how to provide these nonpharmacological approaches to help patients remain calm through crisis.
Key Point #9: Use Nonpharmacological Pain, Agitation, and Delirium Management Strategies
The 2013 PAD guidelines emphasize the importance of using nonpharmacological interventions in the prevention and treatment of PAD. The three strong recommendations include preemptive analgesia and/or nonpharmacological interventions (e.g., relaxation) for patients undergoing chest tube removal, early mobilization whenever feasible to reduce the incidence and duration of delirium, and sleep promotion by optimizing the environment, using strategies to control light and noise, clustering patient care activities, and decreasing stimuli at night. Additionally, a weak recommendation suggests preemptive analgesic therapy and/or nonpharmacological interventions may also be administered to alleviate the pain for other (i.e., non-chest tube) types of invasive or potentially painful procedures.
Although not addressed within the guidelines, several additional nonpharmacological interventions that may be beneficial are mentioned within the text. These interventions include the use of music therapy and relaxation techniques as reasonable complementary therapies in pain management, frequent reorientation to reduce anxiety and agitation, and eye patches and earplugs for sleep enhancement. The authors emphasize throughout the text of the guideline that, prior to administration of medications, care should be taken to identify the etiology whenever patients are assessed to have pain, agitation, or delirium. Although determining the cause of PAD may seem like a relatively straightforward process, it is often exceedingly difficult to do in those patients who are unable to effectively communicate their needs (e.g., patients who are receiving mechanical ventilation or are deeply sedated secondary to medications). The inability to communicate needs effectively is associated with feelings of panic, insecurity, stress, anger, worry, and fear, all of which may be misinterpreted by ICU staff as PAD. It is essential that the ICU team provide these patients a way of effectively communicating their needs. Strategies that may help nonverbal ICU patients communicate their needs include obtaining speech language pathology consults, using communication boards, establishing a reliable yes/no signal, lip reading, and providing patients with tools to write their needs.
Several other nonpharmacological strategies have proven successful at reducing the incidence and duration of delirium outside the ICU setting. For example, the often cited interdisciplinary, Hospital Elder Life Program (HELP) has been successful in not only reducing the incidence of delirium in hospitalized older adults but also as an educational resource, improving hospital outcomes (functional decline), providing nursing education, improving retention of nurses, and enhancing satisfaction and quality of care. Interventions used in this program include, but are not limited to, the use of orientation boards, the provision of cognitively stimulating activities at least three times daily, early ambulation, ensuring patients have needed sensory aids (e.g., glasses, hearing aids), nonpharmacological sleep promotion, interdisciplinary rounds and care planning, and oral volume repletion and assistance with feeding. Although not formally studied in the ICU setting, many of these strategies may be helpful.
Although the PAD guidelines suggest that most of the nonpharmacological interventions are "low cost, easy to provide, and safe" this does not mean they will be easy to implement in everyday practice. Team members will need resources and encouragement to make the changes a reality. If the presence of a music therapist or healing touch expert is not possible, ICU team members will benefit from education and guidance on how to provide these nonpharmacological approaches to help patients remain calm through crisis.