Caring-Centric Implementation of Sleep & Pain Initiatives

Kaiser Permanente, Northern California

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Caritas Consortium 2013

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.

Caring-Centric Implementation of Sleep & Pain Initiatives

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 control- i. 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.

…Continued

Caring-Centric Implementation of Sleep & Pain Initiatives

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.

…Continued

Caring-Centric Implementation of Sleep & Pain Initiatives

Caring-Centric Implementation of Sleep & Pain Initiatives

Inspired Contributor(s) 1 : Kristie Hills Kelly Timothy

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Service Area: San Francisco

Medical Center: SFO

Affiliation: PCS

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Year Shared: 2013

Venue: Caritas Consortium

Format: PowerPoint (separate files)

ID #: n/a

1 Names as listed in Lotus Notes, otherwise personal e-mails indicated

Keyword TAGs: Identifier

Consortium2013-July, San Francisco, Podium, Patient Care Services

Hospital Initiatives, Healing Environments, Team, Patients/Families

Descriptor Pain Management, Quiet/Sleep,

Workflow, Care Board/Plan

Sleeping Protocol & Painscape Initiatives

Lack of

REM sleep

Daytime Fatigue

Anxiety &Delirium

Stress & Pain

IntoleranceDelay in healing!

Insulin Resistance

Impaired Cognition

Release of Inflammatory

Cytokines

Release of Stress

Hormones

Elevated BP and

HR

*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.

Why focus on Sleep?

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.

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

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

• 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

Enhancing the sleeping environment

• 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

Where are we with the protocol?

• 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):

Outcomes

Location Nov2012

Dec 2012

Jan2013

Feb 2013

Mar2013

Apr2013

Composite Rate

CVICU 40 75 50 60 45.5 25 48.5

ICU 50 40 42.8 100 60 33.3 51.43

Untreated /

Undertreated

pain in

hospitals

Harms our patients

Harms our relationships with patients

Harms ourselves

Pain & the Caring Sciences

Life in the ICU before painscape…

Common practice pre-Painscape

• Limited medication orders

• Limited assessment tools- Numeric & Wong-Baker 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

Caritas involved in Painscape

• Develop helping – trusting- caring relationships

• Use creative scientific problem-solving methods for caring decision making

CommunicationRelationships

What does it boil down to?

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

• 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

How we implemented change

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 Nov2012

Dec 2012

Jan2013

Feb 2013

Mar2013

Apr2013

Composite Rate

CVICU 80 83.3 100 60 80.5 100 80.7

ICU 83 75 100 100 85.7 83.3 85.6

• 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!

Painscape Reassessment: Where are we and where are we going?

Pain &

Sleep Deprivat-

ion

Acute Physiologic & Psychological

Changes

Increased Stress to Patient

and Family

Decreased Patient

Satisfaction

Decreased Healing

Patient-centered Care to Improve Outcomes: