caring-centric implementation of sleep & pain initiatives
DESCRIPTION
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.TRANSCRIPT
Kaiser Permanente, Northern California
Caritas in ActionHow Caring Science informs and inspires KP caregivers and affirms our commitment to provide our
patients and their families exceptional care
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: