IMPLEMENTATION
OF A HEALTHCARE SYSTEM PRACTICE GUIDELINE
by Ricky Ocampo
Introduction
The healthcare system involves
various professions who have the same goal of ensuring a healthy population.
They include physicians, nurses, pharmacists, administrators, and many other
workers. The professional diversity is brought about by the need for different approaches to treatment and prevention of diseases. It is also necessitated by the wide range of
information about human anatomy, which leads to people specializing in a particular field. Healthcare involves much research, which leads to the discovery of different ways that can
improve the practice. Implementation of new guidelines found from research can
be efficiently through the collaboration of various
disciplines (Melnyk&Fineout-Overholt 2011). The guidelines adopted in the hospital affect
different professions, and they need
thorough research to define them.
Healthcare System
Practice Guideline
In my current job at Kaiser Permanente, there are various employees who work together to ensure patients are
fully healthy and out of danger. As a critical care nurse, I have to work hand in hand with workers of different
disciplines. Patients in need of critical care are delicate, and caution and professionalism need to be exercised at every given moment to avoid fatal mistakes.
Various guidelines are used to provide a framework for patient care and intervention. The guidelines have to be adhered
to by all workers in the ICU to ensure proper coordination of care and
intervention procedures (Reardon et al. 2013).
One such guideline is the management of delirium, agitation, and pain in adult
patients in the intensive care unit. It offers practical
approaches to handling patients in ICU who
is waiting for, or has undergone a surgical procedure, or for any patient with
a severe medical condition. The guideline’s target population is adult patients over 18 years old. The instruction was made to propose best practices for
preventing, treating, and assessing pain, agitation, and delirium (PAD) to in
adult patients (ICU)(Barr et al. 2013).
The guideline recommends strategies for managing delirium,
agitation, and pain to improve ICU outcomes. This can be done with an
interdisciplinary ICU team approach that includes provider education,
preprinted and/or computerized protocols, and order forms. ICU rounds checklists to monitor the use of pain,
agitation, and delirium management guidelines or protocols in adult ICUscan
also be used.Promoting sleep in adult ICU
patients by using strategies to control noise
and light, decreasing stimuli at night, clustering
patient care activities, and to protect patients' sleep cycles is also
recommended by the guideline. A target
light level of sedation or daily
sedation interruption to be routinely used
in mechanically ventilated adult ICU patients is also part of the
recommendations. The guideline also mentions that
in mechanically ventilated adult ICU patients analgesia-first sedation should be used. Using specific modes
of mechanical ventilation to enhance sleep in mechanically ventilated ICU
patients is not advised since there is insufficient
evidence to prove the efficacy of these interventions (Barr et al. 2013).
How Different
Professions in the Healthcare System are Held to the Guideline
The various
jobs in the system that have to follow the guideline are nurses,
pharmacists, physicians, and respiratory care practitioners. The nurses in the ICU
handle care of the critical patients,
which include administering fluids, and drugs that are prescribed by the
physician. They are also in responsible for cleaning
the patient, conducting, and recording various tests on the patient such
as blood test and blood pressure and temperature (Shorter &Stayt 2010). The
guideline offers recommendations on patient care in the ICU therefore binding
the critical care nurses. The directive
mentions various ways of ensuring patient avoids pain such as by ensuring there
is mobility, which falls directly on the
work of the nurses. There are also
recommendations on drug administration of drugs, monitoring, and recording the
patient’s delirium, agitation, and pain levels to ensure that appropriate
intervention strategies are utilized which are also roles of the critical care
nurse (Warlan & Howland, 2015).There is also a framework for the education of the recommendations and
monitoring progress among other staff, which also falls the duty of the nurse.
The guideline also provides a way of cooperation between workers of different disciplines in the ICU including
nurses (Hsiang-Ling & Yun-Fang 2010).
The physicians in the ICU are also
impacted by the guideline since they assess the patients and prescribe
treatment methods. A framework on measuring, treating, and preventing the pain,
agitation and delirium is provided which affects the work of the
physician. There also recommendations on
the monitoring of the status of the patient in the ICU, which can also be done by the doctors.
The doctors can also participate in education and decision making on various
recommended issues (Luetz et al. 2014). The guideline also affects the
respiratory care practitioners since they are in charge of establishing and
maintaining airway during intensive care (Norman, 2010). They also work with
life support and mechanical ventilation machines where there are various
recommendations on the use of this equipment on the guideline (Luetz et al.
2014).
The pharmacists handle medicine in the hospital, which includes
processing medication orders, expediting the arrival
of medication, and monitoring the drug
administration and effects. The guideline mentions drugs that should be offered to patients experiencing delirium, agitation,
and pain in the ICU, which falls in the line of work of the pharmacists. There
are also recommendations on the titration of some medication, which is part of
the work of the pharmacist. The pharmacists are
also represented in the multidisciplinary team that is also responsible
for education and deliberating on crucial decisions on the implementation of
the recommendations (Hsiang-Ling & Yun-Fang 2010). The professions in the
system ensure that they follow the guideline clearly. An interdisciplinary team
is charged with educating and monitoring
the implementation of the directive.
Evidence used to define
the Guideline
Research was done
to support the implementation of the directive was
done using various online libraries, which included CINAHL, PubMed, and
EBSCOhost. The primary evidence utilized in the directive
is the 2013 American College of Critical Care Medicine/Society of Critical Care
Medicine clinical practice guidelines for the management of pain, agitation,
and delirium in adult patients in the intensive care unit.This guideline is contained in the National
Guideline Clearinghouse (NGC). These guidelines were put to replace “Clinical Practice Guidelines for the Sustained Use of
Sedatives and Analgesics in the Critically Ill Adult” published in Critical
Care Medicine in 2002(Barr et al. 2013).
These guidelines were
formed by the American College of Critical Care Medicine where a multi-institutional
and multidisciplinary task force of 20 people divided into four subcommittees with
expertise in guideline development, delirium, agitation and sedation, and pain
management and associated outcomes in adult critically ill patients.
The task force collaborated over six years
in person via electronic communication
and teleconferences. The subcommittees developed relevant clinical questions,
reviewed, evaluated, and summarized the literature to develop clinical recommendations and statements (Barr
et al. 2013).
The methods used to
collect evidence for the guideline is by a search through electronic databases
which include the International Pharmaceutical Abstracts, PubMed, ISI Web of
Science, Scopus, CINAHL, Cochrane Database of Systematic Reviews and MEDLINE.
The researchers developed an extensive list of related keywords and a professional librarian organized and expanded this key
word list. The librarian also created a corresponding medical subject heading
(MeSH) terms, searched relevant databases, and
with RefWorks software he created a Web-based database. The search
parameters included published English-only manuscripts on adult humans from
December 1999 to December 2010. Letters to the editor, case reports,
editorials, studies with less than 30 patients as well as narrative reviews
were excluded (Barr et al. 2013).
The references of the 2002 guideline were also included in the database. Ultimately,
over 19,000 references were listed in the
RefWorks database. The methods used to
assess the quality of evidence for the study include weighting according to a
rating scheme and expert consensus method. The evidence was analyzed through
systematic review with evidence table; review of published meta-analysis and by
meta-analysis. The methods used to formulate recommendations were expert consensus (Delphi) and expert consensus
(nominal group technique) (Barr et al. 2013).
The guideline was validated by internal and external peer review. The guideline
was also reviewed and endorsed by the New Zealand Intensive Care Society, American
Association for Respiratory Care and the American College of Chest
Physicians. The benefits of implementing the guideline are that it provides
suitable methods of management of critically ill adults in the ICU with
delirium, agitation, and pain. The potential harms of the implementation are
the side effects from the medication used to manage delirium, agitation, and pain (Barr et al. 2013).
The assessment methods that were
reviewed by the guideline are detecting and monitoring delirium, assessment of
delirium risk factors, assessment of quality and depth of sedation, and pain
assessment. The treatment and management methods
that were examined were treatment of pain with Thoracic epidural
anesthesia/analgesia, Enterally administered gabapentin, Intravenous (IV)
opioids, Nonopioid analgesics to decrease opioid use and side effects and
Preemptive analgesia and/or non-pharmacologic interventions (e.g.,
relaxation).The treatment of agitation and sedation include sedation strategies
using nonbenzodiazepine sedatives, Electroencephalogram monitoring (EEG),
Objective measures of brain function, Monitoring depth of sedation and brain
function (Barr et al. 2013).
The treatment of
delirium studied in the guidelines is through IV dexmedetomidine, if sedation
is required, routine monitoring of delirium, consideration of delirium risk
factors and early mobilization of adult intensive care unit (ICU) patients.
The strategies for managing delirium,
agitation and pain that were examined include
interdisciplinary ICU team approach where they provide education, preprinted computerized and/or preprinted protocols and
order forms, and quality ICU rounds checklists. Another management method studied is promoting sleep in ICU
patients by controlling noise and light and by decreasing stimuli at night
(Barr et al. 2013).
Pain management methods
reviewed by the guideline include analgesia-first sedation and a target light
level of sedation in mechanically ventilated adult ICU patients or a routine daily
sedation interruption or the prevention methods examined include prevention of delirium
that includes restart baseline psychiatric medications, if needed, sleep
promotion and by identifying delirium risk factors.Prevention
of agitation was also studied. Methods
reviewed include EEG monitoring for patients at risk for seizures, early mobility, and exercise when at goal sedation
level and daily spontaneous breathing trials (SBT). Pain prevention methods
studied include treatment of pain before sedation and non-pharmacologic
interventions and or pre-procedure analgesia (Barr et al. 2013).
The second evidence document that was
used to support the implementation of the guideline is Pain, Agitation, and Delirium Guidelines: Nurses' Involvement in
Development and Implementation. Which
was authored by Judy Davidson, Chris Winkelman, Celine Gélinas, and Anna
Dermenchyan. The article includes the experiences of nurses that served in the
guideline-making panel for the 2013 American College of Critical Care
Medicine/Society of Critical Care Medicine clinical practice guidelines for the
management of pain, agitation, and delirium in adult patients in the intensive
care unit.This study explores the main responsibilities that nurses have
during generation and execution of new practice guidelines (Davidson et al.
2015).
The study also
describes the influence of the guidelines to the nursing profession. The nurses in the guideline-writing
panel were given equal treatment with
other professions represented. According to this article, there are various roles
that nurses can have in the implementation of guidelines such as the nurse
leader. These are the people charged with the responsibility of translating the
recommendation of the new guidelines into practice. The nurse leaders may be
staff nurses serving as project leaders, educators, nurse practitioners,
clinical nurse specialists, directors, managers, supervisors, and charge nurses. The nurse leader should be involved in an inter-professional
committee where various decisions are made on areas where the guidelines
recommended two or more methods such as the selection of assessment tools of
delirium, agitation,and pain(Davidson et al. 2015).
The nurse leaders are also instrumental
in implementing mobility in the ICU since immobility has been noted as one of the chief causes of
complication during critical illness. Complications caused include skeletal
muscle weakness and wasting, contractures, thrombotic events and pressure ulcer
formation. The nurse leader should also measure the impact of change on implementing the guidelines using selected
quality metrics. The nurse leader can
ensure that change is achieved by making
frequent rounds and by educating, coaching, and communicating with the nursing
staff ( Davidson et al. 2015).
Nurse informaticist
is also a role that the nurses can have in the implementation of
guidelines. Nurses in this role use their clinical knowledge to create the
documentation in the electronic medical record (EMR) for use by clinicians. Nurse
informaticists ensure that professional
and regulatory standards are registered
in the EMR. They are a critical part of the implementation of guidelines since the
hospital might need to change the contents of the EMR to meet the new
recommendations. Another role that nurses can play is a staff nurse as a change leader and personnel nurse as change recipient (Davidson et al. 2015).
Conclusion
The healthcare system consists of a collaboration of various people of different disciplines. In my career as a critical care nurse at the
Kaiser Permanente, I have to work hand in hand with various people. A guideline that affects
different workers at my employment place
is the management of delirium, agitation, and pain
in adult patients in the intensive care unit. The guidance offers practical
approaches to handling patients in ICU, who is waiting for, or has undergone a
surgical procedure, or for any patient with a severe medical condition. The
different medical care disciplines that have to follow the guideline are
nurses, physicians, pharmacists, and respiratory care practitioners. The evidence used in the research and implementation
of the guideline includes is the 2013 American College of Critical Care
Medicine/Society of Critical Care Medicine clinical practice guidelines for the
management of pain, agitation, and delirium in adult patients in the intensive
care unit. Pain, Agitation, and Delirium Guidelines: Nurses' Involvement
in Development and Implementation was also
examined for the implementation of
the guideline.
References
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J., Fraser, G. L., Puntillo, K., Ely, E. W., Gélinas, C., Dasta, J. F., & ... Skrobik, Y. (2013). Clinical
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intensive care unit: Executive summary. American Journal of Health-System Pharmacy, 70(1),
53-58.
Davidson,
J. E., Winkelman, C., Gélinas, C., &Dermenchyan, A. (2015).Pain, Agitation, and
Delirium Guidelines: Nurses'
Involvement in Development and Implementation. Critical
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Hsiang-Ling,
W., & Yun-Fang, T. (2010).Nurses' knowledge
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Luetz, A., Balzer, F., Radtke, F. M., Jones,
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Melnyk,
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