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Impact of a nurse engagement intervention on pain, agitation and delirium assessment in a community intensive care unit
  1. Carolyn M Tan1,
  2. Mercedes Camargo2,3,
  3. Franziska Miller1,
  4. Katie Ross2,
  5. Ramez Maximous2,
  6. Priscilla Yung1,
  7. Carl Marshall1,
  8. Dimitra Fleming4,
  9. Madelyn Law3,
  10. Jennifer LY Tsang1,2,5
  1. 1Niagara Regional Campus, Michael G. DeGroote School of Medicine, McMaster University, St. Catharines, Ontario, Canada
  2. 2Medicine, Niagara Health—Saint Catharines Site, St. Catharines, Ontario, Canada
  3. 3Department of Health Sciences, Brock University, St. Catharines, Ontario, Canada
  4. 4Pharmacy, Niagara Health—Saint Catharines Site, St. Catharines, Ontario, Canada
  5. 5Department of Medicine, McMaster University, Hamilton, Ontario, Canada
  1. Correspondence to Dr Jennifer LY Tsang; jennifer.tsang{at}


Background In 2013, the Society of Critical Care Medicine published a revised version of the ICU Pain, Agitation, and Delirium (PAD) guidelines. Immobility and sleep were subsequently added in 2018. Despite the well-established advantages of implementing these guidelines, adoption and adherence remain suboptimal. This is especially true in community settings, where PAD assessment is performed less often, and the implementation of PAD guidelines has not yet been studied. The purpose of this prospective interventional study is to evaluate the effect of a multifaceted nurse engagement intervention on PAD assessment in a community intensive care unit (ICU).

Methods All patients admitted to our community ICU for over 24 hours were included. A 20-week baseline audit was performed, followed by the intervention, and a 20-week postintervention audit. The intervention consisted of a survey, focus groups and education sessions. Primary outcomes included rates of daily PAD assessment using validated tools.

Results There were improvements in the number of patients with at least one assessment per day of pain (67.5% vs 59.3%, p=0.04), agitation (93.1% vs 78.7%, p<0.001) and delirium (54.2% vs 39.4%, p<0.001), and the number of patients with target Richmond Agitation-Sedation Scale ordered (63.1% vs 46.8%, p=0.002). There was a decrease in the rate of physical restraint use (10.0% vs 30.9%, p<0.001) and no change in self-extubation rate (0.9% vs 2.5%, p=0.2).

Conclusion The implementation of a multifaceted nurse engagement intervention has the potential to improve rates of PAD assessment in community ICUs. Screening rates in our ICU remain suboptimal despite these improvements. We plan to implement multidisciplinary interventions targeting physicians, nurses and families to close the observed care gap.

  • critical care
  • healthcare quality improvement
  • nurses
  • performance measures
  • quality improvement

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  • CMT and MC are joint first authors.

  • Presented at This work was presented at ESICM LIVES 2018.

  • Contributors CMT completed the data analysis and wrote this manuscript. MC acquired and analysed the data. FM contributed to the data analysis and implementation of the interventions. KR, GF and ML contributed to the conception and design of this study and implementation of the interventions. RM contributed to the data analysis. PY and CM contributed to the implementation of the interventions. JLYT contributed to the conception and design of this study, implementation of the interventions, and writing and revision of this manuscript.

  • Funding This work was supported by the Ontario Nurses’ Association and the McMaster University, Department of Medicine, E.J. Moran Campbell Internal Research Career Award 2015–2018 (JLYT).

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval Local research ethics committee approval was obtained for this study.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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