Decreasing severe pain and serious adverse events while moving intensive care unit patients: a prospective interventional study (the NURSE-DO project)

Abstract

Introduction: A quality-improvement project was conducted to reduce severe pain and stress-related events while moving ICU-patients.

Methods: The Plan-Do-Check-Adjust cycle was studied during four one-month phases, separated by five-month interphases. All consecutive patients staying more than 24 hours were evaluated every morning while being moved for nursing care (bathing, massage, sheet-change, repositioning). Phase 1 was considered as the baseline. Implemented and adjusted quality-interventions were assessed at phases 2 and 3, respectively. An independent post-intervention control-audit was performed at Phase 4. Primary-endpoints were the incidence of severe pain defined by a behavioral pain scale > 5 or a 0 to 10 visual numeric rating scale > 6, and the incidence of serious adverse events (SAE): cardiac arrest, arrhythmias, tachycardia, bradycardia, hypertension, hypotension, desaturation, bradypnea or ventilatory distress. Pain, SAE, patients' characteristics and analgesia were compared among the phases by a multivariate mixed-effects model for repeated-measurements, adjusted on severity index, age, admission type (medical/surgical), intubation and sedation status.

Results: During the four studied phases, 630 care procedures were analyzed in 53, 47, 43 and 50 patients, respectively. Incidence of severe pain decreased significantly from 16% (baseline) to 6% in Phase 3 (odds ratio (OR) = 0.33 (0.11; 0.98), P = 0.04) and 2% in Phase 4 (OR = 0.30 (0.12; 0.95), P = 0.02). Incidence of SAE decreased significantly from 37% (baseline) to 17% in Phase 3 and 21% in Phase 4. In multivariate analysis, SAE were independently associated with Phase 3 (OR = 0.40 (0.23; 0.72), P < 0.01), Phase 4 (OR = 0.53 (0.30; 0.92), P = 0.03), intubation status (OR = 1.91 (1.28; 2.85), P < 0.01) and severe pain (OR = 2.74 (1.54; 4.89), P < 0.001).

Conclusions: Severe pain and serious adverse events are common and strongly associated while moving ICU patients for nursing procedures. Quality improvement of pain management is associated with a decrease of serious adverse events. Careful documentation of pain management during mobilization for nursing procedures could be implemented as a health quality indicator in the ICU.

Figure 1

Study-design and quality method. This figure represents the quality-improvement process of pain and serious adverse events while moving ICU patients for turning and nursing care procedures. This 20-month process following the P-D-C-A steps was evaluated by four one-month studied phases separated by inter-study phases of four to six months. The present quality improvement process was the third quality process performed in the ICU regarding the management of sedation and analgesia. Consecutive improvement steps were followed according to the Plan-Do-Check-Adjust method for quality-improvement: - P (Plan-step): Multidisciplinary ICU work group creation, choice of the studied procedure and design of the quality improvement process. - D (Do-step): Beginning of the Nurse-Do study by a one-month baseline evaluation of pain management by nurse while moving the patients (studied Phase 1). Educational interventions for optimized pain management by nurse (Nurse-Do) started after the baseline studied phase. - C (Check step): One-month evaluation (Check) of educational interventions (studied Phase 2). - A (Adjust step): Adjustment of educational interventions implicating an increased multidisciplinary team collaboration, one-month evaluation (Check) of adjusted interventions (studied Phase 3). - Consolidation step: one-month control audit of the PDCA quality improvement process (studied Phase 4).

Figure 2

Flow chart of the study.

Figure 3

Incidence of severe pain, serious adverse events and analgesia. This figure shows that the incidence of severe pain and serious adverse events (SAE) decreased across the quality improvement study while the proportion of given analgesia increased. The difference was significant for severe pain (P = 0.04 and 0.02), SAE (P < 0.001 and P < 0.01) and analgesia (P = 0.01 and P < 0.01) between Phase 1 (baseline) and Phases 3 and 4, respectively.