Assessment of analgesia, sedation, physical restraint and delirium in patients admitted to Spanish intensive care units. Proyecto ASCyD

Development and psychometric validation of the Behavioral Indicators of Pain Scale-Brain Injury (ESCID-DC) for pain assessment in critically ill patients with acquired brain injury, unable to self-report and with artificial airway

INTRODUCTION

The aim of this study was to develop and validate the adaptation of the behavioural indicators of pain scale (ESCID) for patients with acquired brain injury (ESCID-DC), unable to self-report and with artificial airway.

METHODS

Multicenter study conducted in 2 phases: scale development and evaluation of psychometric properties. Two blinded observers simultaneously assessed pain behaviours with two scales: ESCID-DC and Nociception Coma Scale-Revised version-adapted for Intubated patients (NCS-R-I). Assessments were performed at 3 time points: 5 min before, during and 15 min after the application of the painfull procedures (tracheal suction and application of pressure to the right and left nail bed) and a non-painful procedure (rubbing with gauze). On the day of measurement, the Glasgow Coma Score (GCS) and the Richmond Agitation Sedation Scale (RASS) were evaluated. A descriptive and psychometric analysis was performed.

RESULTS

A total of 4152 pain evaluations were performed in 346 patients, 70% men with a mean age of 56 years (SD = 16.4). The most frequent etiologies of brain damage were vascular 155 (44.8%) and traumatic 144 (41.6%). The median GCS and RASS on the day of evaluation were 8.50 (IQR = 7 to 9) and -2 (RIQ = -3 to -2) respectively. In ESCID-DC the median score was 6 (IQR = 4 to 7) during suction, 3 (RIQ = 1 to 4) for right pressure and 3 (RIQ = 1 to 5) for left pressure. During the non-painful procedure it was 0. The ESCID-DC showed a high discrimination capacity between painful and non-painful procedures (AUC > 0.83) and is sensitive to change depending on the time of application of the scale. High interobserver agreement (Kappa > 0.87), good internal consistency during procedures (α-Cronbach≥0.80) and a high correlation between the ESCID-DC and the NCS-R-I (r ≥ 0.75) were obtained.

CONCLUSIONS

The results of this study demonstrate that the ESCID-DC is a valid and reliable tool for assessing pain in patients with acquired brain injury, unable to self-report and with artificial airway.

Incidence of unscheduled removal of invasive devices in patients with COVID-19 in intensive care

INTRODUCTION

The rate of unscheduled removal of invasive devices (ID) is an indicator of quality programmes in the critically ill. Our research group performed prevalence analyses since 2010 and another during the pandemic. The aim was to analyse the rates of use and non-planed removal of endotracheal tubes, catheters (central venous and arterial) and enteral catheters in the first wave of the COVID-19 pandemic comparing them with previous rates.

METHODOLOGY

Prevalence study in a polyvalente ICU. After 4 prospective observational analyses (2010, 2011, 2018, 2019) a retrospective analysis was performed (8 March-8 May 2020).

VARIABLES

diagnosis, stay and reason for removal of ID (endotracheal tubes (ET), central venous catheters, arterial catheters and enteral catheters) and rate of reintubation after self-removal of ET. Variables analysed and described as accidental removal rates per 1000 device-days and rates of ID use.

RESULTS

2026 patients were included (631 in 2010, 724 in 2011, 210 in 2018, 361 in 2019 and 100 in 2020). Significant differences, between all periods, in diagnoses (p < 0.001), ICU stay (p < 0.001) and mortality (p = 0.016) and, between 2020 and all other periods, in rates of use per 100 days-stay (p < 0.010) and per 100 admissions (p < 0.001) in all devices except arterial catheter. In 2020, there was an increase in ET obstruction (36.0%; rate 20.27 per 1000 intubation-days, p < 0.010), decrease in ET self-removals (2020 rate: 0.00 per 1000 intubation-days; p < 0.050) and enteral catheters (14.33 per 1000 catheter-days). Overall reintubation (all periods) after self-extubation: 12.5%.

CONCLUSIONS

The rate of devices self-removal in COVID-19 patients in the first wave of the pandemic was lower than that observed in the previous four periods. The high incidence rate of ET obstruction in these patients was significant and relevant.

Patient satisfaction and safety in the administration of sedation by nursing staff in the digestive endoscopy service: a cross-sectional study

BACKGROUND

The satisfaction of patients with sedation by nursing staff is an issue of interest for the quality of health care, influencing the recovery and well-being of patients as well as their confidence in and adherence to treatment. One of the most frequently performed diagnostic and therapeutic tests requiring sedation are digestive endoscopies, so it would be interesting to study satisfaction in these services.

AIM

To determine the level of patient satisfaction and safety with sedation via digestive endoscopies by nurses.

METHODS

This was a cross-sectional study in the Digestive Endoscopy Service at the University Hospital of Toledo, Spain. The sample consisted of 660 adult patients from the digestive endoscopy service who were sedated between June-September 2023. The degree of satisfaction with the service was measured by the questionnaire: Survey of patient satisfaction with the digestive endoscopy service. The study was approved by the ethics committee.

RESULTS

Patients who reported satisfaction with the treatment were very satisfied with the sedation provided by the nurses. The most valued item was the attention of the nursing professionals. The least valued items were the waiting time for the appointment and the time spent in the waiting room on the same day. The incidence of complications recorded during the test were minimal (2% of all patients).

CONCLUSIONS

Most patients are satisfied with the sedation administered by nurses via digestive endoscopies, and complications were rare, supporting the efficacy and acceptance of this practice. Clinical practice guidelines and consensus documents in Spain guarantee that nurses have autonomy to administer sedation in digestive endoscopy services, but there is a lack of national regulations to support this technique. The current consensus in Spain is that specific training is necessary for such nurses.

Behavioral pain scales, vital signs, and pupilometry to pain assessment in the critically ill patient: A cross sectional study

BACKGROUND

Detecting pain in sedated critically ill patients requires utmost attention.

AIM

To assess the pain in mechanically ventilated critically ill patients with the Behavioral Pain Scale (BPS), Behavioral Indicators Pain Scale (ESCID), the pupillary dilation response (PDR), and vital signs.

DESIGN

Cross-sectional study METHODS: The study was conducted between March and December 2019, involving patients with a baseline BPS of 3, ESCID of 0, and RASS between -1 and -4. Patients with mobility limitations or altered pupillary reflexes were excluded. We measured before and after non-painful stimulation (NP) followed by 10-20-30-40 mA stimuli and endotracheal aspirate (ETA). The primary outcome was the pain measured with BPS and ESCID scales and PDR with AlgiScan® pupilometer defined as BPS≥4, ESCID≥1, and PDR≥11,5 %. We performed a descriptive study and analyzed the agreement between pain detection methods.

RESULTS

Thirty-one patients were included, and 183 measurements were recorded. The scales showed minimal changes. Approximately 30 % of patients reported pain at a 30 mA stimulus, increasing to over 70 % after ETA. The PDR ranged from 2 % to 6-33% on the ETA, even in pain-free patients, with pain incidence between 70 % and 100 % for the 40 mA and ETA stimuli. Vital signs did not show relevant changes. The PDR had over 90 % agreement with scales for no pain. For higher-intensity stimuli, agreement ranged from 60 % to 80 %. Disagreement occurred when there was no pain by scales (BPS<4; ESCID<1) and pain with PDR (PDR≥11.5).

CONCLUSIONS

Pain behavioral scores and vital signs were low in critically ill patients. PDR detected a nociceptive pain response in no-pain patients.

The use of mechanical restraint in critical care units: Characterisation, application standards and related factors. Results of a multicentre study

OBJECTIVES

To describe and characterise the use of mechanical restraint (MR) in critical care units (CCU) in terms of frequency and quality of application and to study its relationship with pain/agitation-sedation/delirium, nurse:patient ratio and institutional involvement.

METHOD

Multicentre observational study conducted in 17 CCUs between February and May 2016. The observation time per CCU was 96 h. The main variables were the prevalence of restraint, the degree of adherence to MR recommendations, pain/agitation-sedation/delirium monitoring and institutional involvement (protocols and training of professionals).

RESULTS

A total of 1070 patients were included. The overall prevalence of restraint was 19.11%, in patients with endotracheal tube (ETT) 42.10% and in patients without ETT or artificial airway it was 13.92%. Adherence rates between 0% and 40% were obtained for recommendations related to non-pharmacological management and between 0% and 100% for those related to monitoring of ethical-legal aspects. The lower prevalence of restraint was correlated with adequate pain monitoring in non-communicative patients (P < .001) and with the provision of training for professionals (P = .020). An inverse correlation was found between the quality of the use of MR and its prevalence, both in the general group of patients admitted to CCU (r = -.431) and in the subgroup of patients with ETT (r = -.521).

CONCLUSIONS

Restraint is especially frequently used in patients with ETT/artificial airway, but is also used in other patients who may not meet the use profile. There is wide room for improvement in non-pharmacological alternatives to the use of MC, ethical and legal vigilance, and institutional involvement. Better interpretation of patient behaviour with validated tools may help limit use of MR.

Pain Behaviors Analyzed by Videorecording in Brain-Injured Patients Admitted to the Intensive Care Unit

AIM

To describe and classify pain behaviors (facial and body) in brain-injured patients with a low level of consciousness before, during, and after the performance of painful and non-painful care procedures.

METHODS

Facial behaviors and body movements in brain-injured patients were videotaped at rest, during the application of three care procedures (two painful and one non-painful), and 15 minutes after completion of these procedures. Each video recording was evaluated by expert evaluators blinded to each other. For each of the behaviors observed, all possible combinations between the three procedures and/or time were compared using the McNemar test. Effect size was measured by the difference in proportions using the Wilson score 95% confidence intervals.

RESULTS

Twenty-seven patients were included. The mean (standard deviation) Glasgow Coma Score was 5.4 (1.9). A total of 33 behaviors (29 active, four neutral) were registered. Expression of behaviors was more common during the painful procedures compared with the other time points (non-painful procedures, baseline, and final evaluation). Inter-evaluator agreement was substantial (Kappa index >0.7) in more than 50% of the observed behaviors.

CONCLUSIONS

In this study involving brain-injured patients with a low level of consciousness, facial, body, and ventilation-related behaviors were more common during painful procedures. Agreement between evaluators to detect the presence or absence of these behaviors was substantial. These findings underscore the need to develop pain assessment measures specific to this patient population.

Physical Restraint Use in Intensive Care Units: Exploring the Decision-Making Process and New Proposals. A Multimethod Study

Aim: The general aim of this study was to explore the decision-making process followed by Intensive Care Unit (ICU) health professionals with respect to physical restraint (PR) administration and management, along with the factors that influence it. Method: A qual-quant multimethod design was sequenced in two stages: an initial stage following a qualitative methodology; and second, quantitative with a predominant descriptive approach. The multicenter study was undertaken at 17 ICUs belonging to 11 public hospitals in the Madrid region (Spain) across the period 2015 through 2019. The qualitative stage was performed from an interpretative phenomenological perspective. A total of eight discussion groups (DG) were held, with the participation of 23 nurses, 12 patient care nursing assistants, and seven physicians. Intentional purposive sampling was carried out. DG were tape-recorded and transcribed. A thematic analysis of the latent content was performed. In the quantitative stage, we maintained a 96-h observation period at each ICU. Variables pertaining to general descriptive elements of each ICU, institutional pain-agitation/sedation-delirium (PAD) monitoring policies and elements linked to quality of PR use were recorded. A descriptive analysis was performed, and the relationship between the variables was analyzed. The level of significance was set at p ≤ 0.05. Findings: A total of 1070 patients were observed, amounting to a median prevalence of PR use of 19.11% (min: 0%–max: 44.44%). The differences observed between ICUs could be explained by a difference in restraint conceptualization. The various actors involved jointly build up a health care culture and a conceptualization of the terms “safety-risk”, which determine decision-making about the use of restraints at each ICU. These shared meanings are the germ of beliefs, values, and rituals which, in this case, determine the greater or lesser use of restraints. There were different profiles of PR use among the units studied: preventive restraints versus “Zero” restraints. The differences corresponded to aspects such as: systematic use of tools for assessment of PAD; interpretation of patient behavior; the decision-making process, the significance attributed to patient safety and restraints; and the feelings generated by PR use. The restraint–free model requires an approach to safety from a holistic perspective, with the involvement of all team members and the family.

Pain assessment of the adult sedated and ventilated patients in the intensive care setting: A scoping review

BACKGROUND

Pain is frequently encountered in the intensive care setting. Given the impact of pain assessment on patient outcomes and length of hospital stay, studies have been conducted to validate tools, establish guidelines and cast light on practices relating to pain assessment.

OBJECTIVE

To examine the extent, range and nature of the evidence around pain assessment practices in adult patients who cannot self-report pain in the intensive care setting and summarise the findings from a heterogenous body of evidence to aid in the planning and the conduct of future research and management of patient care. The specific patient cohort studied was the sedated/ ventilated patient within the intensive care setting.

DESIGN

A scoping review protocol utilised the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping review checklist (PRISMA-ScR).

METHODS

The review comprised of five phases: identifying the research question, identifying relevant studies, study selection, charting the data and collating, summarizing, and reporting the results. Databases were systematically searched from January to April 2020. Databases included were Scopus, Web of Science, Medline via Ovid, CINAHL COMPLETE via EBSCO host, Health Source and PUBMED. Limits were applied on dates (2000 to current), language (English), subject (human) and age (adult). Key words used were "pain", "assessment", "measurement", "tools", "instruments", "practices", "sedated", "ventilated", "adult". A hand search technique was used to search citations within articles. Database alerts were set to apprise the availability of research articles pertaining to pain assessment practices in the intensive care setting.

RESULTS

The review uncovered literature categorised under five general themes: behaviour pain assessment tools, pain assessment guidelines, position statements and quality improvement projects, enablers and barriers to pain assessment, and evidence appertaining to actual practices. Behaviour pain assessment tools are the benchmark for pain assessment of sedated and ventilated patients. The reliability and validity of physiologic parameters to assess pain is yet to be determined. Issues of compliance with pain assessment guidelines and tools exist and impact on practices. In some countries like Australia, there is a dearth of information regarding the prevalence and characteristics of patients receiving analgesia, type of analgesia used, pain assessment practices and the process of recording pain management. In general, pain assessment varies across different intensive care settings and lacks consistency.

CONCLUSION

Research on pain assessment practices requires further investigation to explore the causative mechanisms that contribute to poor compliance with established pain management guidelines. The protocol of this review was registered with Open Science Framework (https://osf.io/25a6) Tweetable abstract: Pain assessment in intensive care settings lacks consistency. New information is needed to understand the causative mechanisms underpinning poor compliance with guidelines.