Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium (PAD) in Adult Patients

Introduction

This paper discusses Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium (PAD) in Adult Patients in the Intensive Care Unit, that were published in 2013 after a revision of the previous version, the "Clinical Practice Guidelines for the Sustained Use of Sedatives and Analgesics in the Critically Ill Adult," used in as from 2002, published in the Critical Care Medicine (Pandharipande et al., 2017). The authors of the guidelines were Juliana Barr, Gilles Fraser, Kathleen Puntillo, and Wesley Ely among others.

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The healthcare system practice guidelines are important for nurses and all clinicians to care for patients suffering from various conditions effectively. The practice guidelines need to be based on evidence, available research, and practice experiences in nursing. Optimal patient care depends on a systematic review of the evidence, and evaluations of both limitations and benefits of previous practices to develop the best alternative care option. The clinical guidelines are significant in the medical practice and necessary for the well-being of patients. The clinical practice guidelines are evidenced-based approaches that integrate the best available research evidence with patient values and clinical expertise to enhance care outcomes. The techniques or methodology entails asking relevant clinical research questions, identifying the best evidence to offer solutions, applying the same to practice, and evaluating the results based on the clinical outcomes.

Guidelines Overview

In intensive care unit (ICU) department, the responsible medical practitioners must be guided by the policies and guidelines to ensure safe and secure medical procedures to the patients. The patients in the ICU are likely to suffer pain, agitation, and delirium. The Clinical Practice Guidelines for the Management PAD were introduced to eliminate the problems and provide comfort to the adult patients admitted to the ICU department. The guidelines have enabled significant advances in the understanding the psychological and physical environment for ICU patients. The suggestions of the guidelines include the development of reliable and valid bedside assessment tools that measure sedation, pains, delirium, and agitation in the patient, which allows the management of patients to assess and evaluate the outcomes linked to both pharmacologic and non-pharmacologic interventions. The guidelines help in the improvement of clinical medications administered to respond pains, agitation, and delirium (PAD) in ICU adult patients (Barr et al., 2013). Medical practitioners come to realization and appreciation of both short and long-term effects after a prolonged exposure to PAD. The change of the administration methods and titration of medications can affect the ICU patient outcome as much as the choice of drug. Ensuring that the critically ill ICU patients are free from PAD requires a safe and efficient approach and a light level of sedation that still ensures patients' comfort while still maintaining improved medical outcomes.

The elimination of PAD may sometimes conflict with other health management goals, for instance, cardiopulmonary stability, but preserves the end organ function and perfusion. In addition, the clinical management goals may as well be complicated by the bulging number of evidence-based clinical algorithms and bundles, some of which other regulatory agencies and players already adopted (Knottnerus & Buntinx, 2009). The final challenge of the implementation of evidence-based practices is due to the worldwide philosophical, cultural, and practical norms as well as the unavailability of manpower and resources.

The main goal of these ICU clinical guidelines is to recommend the evidenced-based best practices for managing PAD and to enhance the clinical outcomes in adult ICU patients. The assessment of evidence performed to recommend these practice guidelines were rigorous, objective, unbiased, and transparent, balanced against the preferences of family members, payers and regulatory groups, ICU patients, and caregivers. There are very crucial techniques that can help the ICU patients in medical improvement just by the bedside. The scope of the guidelines is both short and long-term PAD management in non-intubated and intubated adult surgical, trauma, and medical ICU patients. The guidelines address the debates on sedation and analgesia for procedures, described in details in the American Society of Anesthesiologists practices on conscious sedation (Barr et al., 2013).

The significance of these guidelines is that it places an emphasis on the psychometric concepts of PAD monitoring tools, and entails both non-pharmacologic and pharmacologic techniques to manage PAD in adult ICU patients. Also, there is a high level of understanding due to the emphasis placed on preventing, diagnosing and curing delirium, which reflects the growing understanding of the diseases in critically ill patients. According to Barr and others, the guidelines help clinicians to take more integrated methodologies to manage and regulate PAD in ICU or critically ill patients. These policies need to be adopted in the context of patient's care needs, and resource availability of the local healthcare facilities. They are not absolute or prescriptive in regard to terms.

Different Professionals and the Guideline

Based on the evidence-based practices, the medical bodies select a panel responsible for guidelines formulations. The guidelines enforcers are the medical institutions and bodies as well as the practitioners' work ethics bodies (Malcolm, 2016). Therefore, the evidence regarding a quality improvement need informs the decision of the medical bodies to develop the health guidelines.

The implementers of the guidelines are the doctors, nurses, pharmacists, and clinical officers, who must uphold proper in-house care to eliminate pain, agitation, and delirium in adult patients in the ICU. The role of the nurses is to ensure that the patient has a proper environment before administration of any procedure. Once the guidelines are published, it is the role of the nurses to implement the new recommendations into practice and eliminate the previous practices. The nurses involved in the process include the clinical nurse specialist, nurse informaticist, nurse educator, nurse practitioner, and staff nurse. The nurses' involvement is desired, having a primary role in patient assessment (Cherry & Jacob, 2016). The nurses are leaders in change promotion since they are often with the patients and understand their needs better than other practitioners. Moreover, the nurses are also the recipients of the planned changes in ICU practices. The PAD guidelines allow professionals to conduct the routine assessments of pain in all ICU patients.

The doctors have a role in prescribing the medications necessary for the PAD-suffering ICU patients. The pharmacists have a role of providing the medicines to alleviate pains. The PAD guidelines are, therefore, applicable to nearly all the medical professionals who deal with the ICU patients. The guidelines constantly remind the key players to ensure alleviation of harm by routinely analyzing the patients' conditions before carrying out any medical procedures (Cherry & Jacob, 2016). It is important to audit the responsible practitioners to ensure professionalism and wellbeing of the patients who are in the critical illness situations. The practitioners should give regular feedback regarding the implementation of the guidelines and issue recommendations for improvements based on the evidence and the performance during the execution of the changes.

Research Works Used to Adopt the Guidelines

According to Saylor (2010), the evidence-based practice is a lifetime approach to clinical practice that integrates the principles of systematic search or research on the evidence of treatment, its appraisal, and synthesis. It also entails the principle of clinical expertise to establish the unique status of patients and diagnose the issue. Lastly, it entails the preferences and values of patients. The impact of the evidence-based practice is to translate the learned knowledge into a goal of enhancing clinical practices.

There are several references and research that were used to adopt the ICU PAD practice guidelines. One of the sources that prompted the guidelines development was the previous guidelines that required an update; "Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult" by Jacobi et al. (2002). Research entailed a systematic investigation of the factors and issues that affect the adult ICU patients. This source is qualitative evidence that showed that pain, agitation, and delirium are the main problems that ICU patients often suffer and need to be managed. The quantitative aspect of the research was conducted by the American College of Critical Care Medicine, which identified a task force of 20 persons from multidiscipline areas and with expertise in guidelines development and PAD associated outcomes in ICU patients (Barr et al., 2013). The task force developed research questions and carried out thorough evaluations to develop descriptive statements and actionable recommendations. The research conducted was related to pain and analgesia, delirium, and agitation and sedation, and their associated clinical outcomes in the critically ill patients. The researchers also applied the use of psychometric analysis to assess and compare the PAD assessment tools. The references or literature were reviewed and statements and recommendations issued for implementation. The recommendation strengths were ranked as either weak (-1) or strong (+1) while the quality of evidence was ranked as high, moderate, and low (Barr et al., 2013). The absence of evidence called for the help of the expert opinions to address the likely conflict of interests in related research.

The Evidence Used To Define the PAD Guidelines in Critically Ill Patients

There are several pieces of evidence regarding the pains, agitation, and delirium in critically ill adult patients in ICU. This factor is what leads to the PAD guidelines development. The outcome-based model was recommended for ICU health practitioners depending on the benefits as well as risks due to implementation. The effective guidelines were adopted depending on cost-effectiveness, validity, reliability, reproducibility, clinical applicability, clarity, representative development, scheduled and unscheduled review, and meticulous documentation. Guidelines that ignore these aspects may be recommended with major implications on resources and poor patients' outcome.

Studies show that patients in medical, trauma and surgical ICU routinely experience pains both at rest and during routine ICU care (Barr et al., 2013). Procedural pain is more frequent in adult ICU patients. Pain is common in adult patients' cardiac surgery, and women even experience more pain after cardiac surgery than men. In agitation and sedation, light level of sedation in critically ill patients is associated with improved clinical outcomes, which include a shorter stay in ICU and shorter period of mechanical ventilation. There is need to manage delirium because it is strongly associated with death in adult ICU patients. Furthermore, evidence shows that it is associated with longer length of stay by the adult critically ill patients in ICU. It is also moderately linked to the developments of post-ICU cognitive impairments in the adult patients in ICU. Other evidence-based arguments according to Barr et al. are as follows; delirium is associated with severity of illness on patient admission, pre-existing dementia, alcoholism, and hypertension.

Level of Evidence

The current...