How we do pain assessment: Critical-Care Pain Observation Tool

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What is the Critical-Care Pain Observation Tool (CPOT)?

The CPOT is a behavioural assement pain scale. The CPOT includes evaluation of four different behaviours (facial expressions, body movements, muscle tension, and compliance with the ventilator for mechanically ventilated patients or vocalisation for non-intubated patients) rated on a scale of zero to two with a total score ranging from 0 to 8. The CPOT is feasible, easy to complete, and simple to understand. The full itemised CPOT, descriptions of behaviours and directives for use are available here.

When should we use CPOT?

The gold standard for the evaluation of pain is still patient self-report. When this is not possible, due to sedation, intubation/mechanical ventilation or delirium, the CPOT should be used. In my unit we have chosen CPOT due to a clinical governance group consensus that the supporting literature for ICU behavioural pain scales demonstrates that CPOT has been validated in patient groups that are most similar to our ICU case-mix.

Why do we need another assessment tool?

The addition of a pain assessment tool specifically validated in both mechanically ventilated and delirious ICU patients, allows us to deliver more objectively targeted pain relief and achieve a greater balance between sedation and analgesia. It also allows us to more reproducibly assess the efficacy of our pain relief interventions, both pharmacological and non-pharmacological. Currently available options for pain assessment of the non-speaking or delirious patient are highly subjective and therefore difficult to reproduce from one clinician to the next. It is difficult to determine whether this predisposes patients to excessive or inadequate analgesia.

In combination with our use of the Richmond Agitation-Sedation Scale (RASS) to set targets for sedation choice, CAM-ICU Delirium assessment to screen for the presence of delirium, and the careful selection of sedative and analgesic agents (see ICUdelirium.org protocol for example), we are aiming to reduce the rate of ICU associated delirium and potentially reduce the number of days patients require mechanical ventilation. These practices align with the recommendations made in the Society for Critical Care Medicine Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit.

How can you quickly and easily calculate the CPOT?

In my ICU we have a CPOT calculation and assessment guide in our clinical information system. There is also a great website that provides a huge number of medical scoring calculators, MDCalc. They also have a free App. The MDCalc CPOT calculator is available here.

Watch the video below for an overview and examples of the CPOT assessment

Where can I find more resources for best practice in ICU sedation, pain and delirium management?

 

All About That Base? Why Nursing Needs More Than Evidence

Evidence-based nursing. This is the focus of most of the modern nursing discourse (including this blog! Controversy ahead…). In all of nursing’s domains of practice, evidence-base is a hot topic, showing that we are up-to-date, safe, and professional.

There’s just one problem. Being ‘evidence-based’ does not mean nursing is any of these things.

Our profession has doubled down on evidence-based framing in recent years, in alignment with medical professionals. This is nothing new; nursing pioneers have long aligned nursing with aspects of the natural sciences and medical sciences in order to give nursing credibility[i]. I get the sense that nursing’s drive towards evidence is to appear credible alongside medicine, as much as it is to actually improve patient care.

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There are several reasons why evidence is not enough to form the basis of nursing knowledge:

  1. Evidence is not automatically right or good.

One only needs to say “Wakefield” and we know that scientific evidence can be flawed[ii]. While this is an extreme example, there are many published studies that are not rigorous or are clouded by conflicts of interest. Just because something has been studied or published does not make it accurate, safe, or useful.

  1. The knowledge to practice gap is slow.

Estimates vary, but we know it can be 10-17 years for knowledge to be translated into practice. Even then, it is extremely difficult to change nursing (or medical) practice, and have these changes last. And waiting 2 decades for changes in practice won’t serve our patients in the meantime.

  1. Standardization is not a good idea.

We know that evidence does not necessarily serve all people or populations. For example, when a study shows that an intubation technique works well in one setting, it does not mean it is safe for all settings. The idea that, if we standardize our care, we will improve patient safety, is fundamentally flawed[iii].

  1. In many cases, evidence does not exist.

How should nurses practice in the context of Zika virus? We are still learning this. There are patients with Zika who need care in the meantime, and we can’t wait until we have an answer to nurse them.

  1. Evidence is not ethically neutral.

Evidence is influenced by politics and economics, from start to finish. There are important issues which have not been researched because there isn’t funding available, or other issues are more politically attractive. Even when evidence is available, it can be difficult to fund or adopt; safe staffing ratios are a prime example. Greatest need does not always drive research priorities or implementation.

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So what are nurses to do?

I advocate a return to a comprehensive understanding of what makes up nursing knowledge. Carper wrote this paper in 1978[iv], and it’s still relevant and useful today.

Carper outlined that nursing has 4 kinds of knowledge:

  1. Art
  2. Science
  3. Ethics
  4. Experience

If we return to seeing nursing practice as a comprehensive body of knowledge, we can outline nursing work as being multidimensional. Evidence-based nursing has us leaning so heavily on science, that we lose the other factors in our conversations about nursing.

When we are supporting people with mental illness, we know that if we provide community supports, medication, and cognitive-behavioral therapies, we will have better outcomes than if we provide medication alone. This same logic can apply to how we use Carper’s types of knowledge.

We can form the basis of our practice with the art of nursing. We can say, no matter who I meet today, I will promote their dignity, or I will be caring, or whatever works in your practice. When we have a specific problem, such as acute kidney injury, we can use our scientific knowledge and our experience to provide expert care. We can advocate for vulnerable people because this is part of the ethics of nursing. These types of knowledge work together, and give us comprehensive nursing practice.

I think most nurses already integrate different types of knowledge in their practice. What we can change is how we talk about it. We can talk about how we apply different types of knowledge in our work. If we explain nursing knowledge in these domains, it may support nursing students to develop their practice. It may also be easier to talk about challenges, such as ethical dilemmas, when we move away from an overemphasis on evidence.

I believe in the vital role of evidence in nursing practice, as I am a nurse researcher, working to build our professional knowledge base. But I also see that we need more, and we can steer our professional conversation back to the multi-faceted knowledge that really makes up our base.


References

[i] Wuest, J. (1994). Professionalism and the evolution of nursing as a discipline: A feminist perspective. Journal of Professional Nursing10(6), 357-367.

[ii] Godlee, F., Smith, J., & Marcovitch, H. (2011). Wakefield’s article linking MMR vaccine and autism was fraudulent. BMJ342, c7452.

[iii] Learn more: http://resiliencecentre.org.uk/fact-sheets/safety-i-and-safety-ii/ Full disclosure- I am a member of the Centre for Applied Resilience in Healthcare.

[iv] Carper, B. A. (1978). Fundamental patterns of knowing in nursing. Advances in nursing science1(1), 13-24.

 

Das SMACC Program and Ticket Information

Das SMACC – Berlin

The Social Media and Critical Care Conference continues to harness the immense energy of FOAM and dasSMACC in Berlin June 26-29 2017 promises to be the best one yet.

 Two of the editorial team from Injectable Orange (Ashley and Jesse) are members of the SMACC Organising Committee – so this post is both positively biased and factually correct

SMACC has seen spectacular growth since its humble beginnings. The Conference has grown from an enthusiastic idea into a global leader amongst critical care events. Whilst SMACC is primarily a high quality, academic meeting, the real reason behind this growth is the enormous and inspiring energy of the critical care community itself. A community that crosses traditional hierarchies, professional barriers and international borders. This is a community dedicated to innovation, teaching and learning. A community based around the pursuit of excellence in patient care, and a passion for sharing this as widely as possible.


What ’s in the program and registration at a glance for 2016?

We have taken all your feedback into consideration and planned for:

  • Another massive day of workshops on Monday, 26th June 2017 (WORKSHOPS)
  • A single stream format only featuring the best of the best (PROGRAM)!
  • The most incredible venue: the Tempodrom
  • Fabulous accommodation deals which are essential this year as Das SMACC is just before fashion week (ACCOMMODATION)
  • Registration details are here
  • The continued innovation and convenience of onsite childcare (crèche)
  • A bigger and better SMACC party. Yes, it will be massive.
  • SMACCrun will be back with scenic options for great running tracks near the Potsdamer Platz precinct

What Makes SMACC Different?

So, why did the SMACC conference SELL OUT all 2000 delegate registrations in minutes?

To begin with, the affiliated websites supporting SMACC represent a comprehensive list of the “who’s who” in the FOAM world. The talented clinicians behind these websites have come together and harnessed their innovation, vitality and expertise to create the SMACC experience. The strong social media connections inherent to SMACC result in an ongoing, online conversation, which in turn, empowers the delegate and enhances their experience. SMACC is focused on being a conference truly for the delegates. Delegates have a say in every aspect of the meeting, including the speakers chosen, program topics, themes and styling, social events, and the questions asked in sessions. This level of delegate interaction with the conference is unparalleled in critical care.

There have also been many positive lessons learned from the FOAM world, which have now been translated into the SMACC Conference. Lessons on how to engage, inspire and make critical care education enjoyable. We keep the talks short (15-20 minutes), choose the topics carefully, handpick speakers who we know can both educate and inspire, and discourage reliance on power point presentations. Of course, all the sessions are recorded and podcast to be released in a FREE series – creating more great FOAM!

But SMACC isn’t just about the academic presentations. SMACC is an experience. The opening ceremony, the themes of the exhibition hall and welcome events, the teas and lunches provided in the breaks and the massive Gala night, all of which are included in the one registration price, are designed to bring the group together and enhance the feeling of belonging to one critical care
community.


Why Berlin?

Berlin is an amazing and vibrant city and has the energy capable of hosting SMACC. It is no surprise that it has become the artists’ capital of Europe. There is an intriguing combination of grittiness, openness, willingness and enthusiasm in the Berlin community, which make it a perfect destination for the FOAM community. Of course that’s to say nothing of the history, museums and bars.

Berlin is also perfectly situated in the heart of Europe to springboard any European adventure.


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Das SMACC Ticket Release

Delegate numbers are capped at approximately 2000 registrations again this year  as we believe this is the best  size to maintain our FOAM community atmosphere.  In an attempt to be as fair as possible here are the basics of how it will work:

  1. Registration will open on Wednesday, 26th October at 0800 Sydney EST – see here for your local time.
  2. There will be 3 separate ticket releases: the major release will be as above on Wednesday, 26th October, a smaller allocation will be released on Wednesday, 7th December and a final limited release on Wednesday, 1st February 2017
  3. Your best chance will be with the first release, but if you really need to wait until you have leave confirmed then you can chance your hand on the February release
  4. All prior delegates will receive an email reminder the week before tickets go on sale, but there is no other preference (first in best dressed!)
  5. Owing to the limited number of spots there will be no DAY ONLY registrations issue
  6. Workshop registration also opens on Wednesday, 26th October and like last year will be on a first come first served basis
  7. If you miss out on a ticket there will be a waiting list
  8. If you miss your preferred workshop there will also be a waiting list

Thanks for the Craic, Now For DAS SMACC

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If you are a nurse working in any spectrum of the care pathway for the critically ill patient, SMACC is the conference for you. If you have just woken from a coma or stumbled into the world of the interwebs, below is a brief history and taste of things to come. For the seasoned SMACCers, you will notice a radically overhauled and ultra vibrant new website – http://www.smacc.net.au

This is a truly open conference – nobody is too “special” for a coffee line conversation. What’s more two of our editorial team (Ashley and Jesse) are proud members of the Organising Committee (of which three members are Nurses!). There are few professional development activities that make you want to go back to work and lift up those around you, start a blog or podcast or just present, teach or mentor better. In a time where much of the popular online presence for nursing is tangled up with materialism and commercial self-interest we need to step up, show ourselves as professional role models interested in evidence and research and political discourse. We need to tear down walls, form communities of practice and expand our peer group far beyond the people we work with on a day-to-day basis.


DAS SMACC


On September 3rd, the SMACC Team premiered the SMACC DUB Documentary. This 8 minute video gives a great insight into what make SMACC special – the people, the connections, the knowledge and the show!

SMACCDUB – The Craic Redux from Social Media and Critical Care on Vimeo.

 


The program and registration details for DAS SMACC will be coming very soon. Keep up to date by following @smaccteam on Twitter or like the SMACC Conference Facebook page. If you are new to Twitter or just considering dipping a toe in, check out this guide to get you Tweeting like a pro in no time. Join the conversation!

Goal Directed Simulation at TTC Downunder

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On July 13th we will be facilitating a super-charged techniques of simulation workshop to some brilliant clinician educators at The Teaching Course Downunder. In order to maximise our 4hrs together, we have curated some of the best FOAM simulation resources available.

Learning Objectives

1)      Participants will learn how to identify opportunities for quality improvement that may be addressed through simulation.

2)      Participants will learn how to manipulate stress to optimise learning outcomes in simulation.

3)      Participants will learn the importance of pre-brief and debrief in simulation and how this differs between workplace and simulation centre course.

4)      Participants will learn how to enhance the psychological realism of simulation.


homeworkThe course participants are asked to complete the following exercise in readiness for the workshop: SMART Goals for Simulation. We will be reviewing and discussing examples in the small group break out sessions.


The sessions will include:

Goal Directed Sim – Jesse Spurr & Clare Richmond

Titration of Stress – Chris Nickson

The Fiction Contract – Confederates, Acting and Simulated Patients  – Clare Richmond & Will Sanderson

Pre-brief – the Foundation of Safe and Effective Sim – George Willis & Jen Williams

Debriefing Q&A Panel – George Willis, Clare Richmond, Jen WIlliams and Ross Fisher – moderated by Jesse Spurr

#FOAMed


General Overview of In Situ Goal-Directed Sim

Injectable Orange –  Simulation Basics – Back to the Future Podcast

St Emlyn’s – Top Ten Tips for In Situ Sim Blog and Podcast

Injectable Orange – Tips for Team Simulation blog

ICN — Guerilla Sim: Anyone, anytime, Anywhere (Jon Gatward’s talk at SMACC 2013)

LITFL CCC — In situ simulation (overview of pros and cons and safety issues in in situ simulation)


Building Fidelity in In Situ Simulation – Fiction Contract

Injectable Orange – Plants in Simulation Vodcast

St Emlyn’s – Actors in Simulation (Nice review of Natalie May’s simulation experiences at SWEETs 15)

KI Docs — Tim Leeuwenburg’s excellent Simulation apps review

Sanko et al Establishing a Convention for Acting in Healthcare Simulation


Titration of Stress in Simulation – Stress Inoculation

SMACCUS Stress Inoculation Training – Intro podcast from the Swami

Life in The Fast Lane – Review of Stress Inoculation Training workshop + resources a plenty

EMCrit – Stress Inoculation Training (a brilliant post from Mike Lauria)


Pre-briefing and Debriefing – The Bread of the Sandwich

Jenny Rudolph and Harvard Sim Team – Establishing a safe container for learning in simulation: The role of pre-simulation briefing – Journal article 

iTeachEM  Thorough Vodcast overview of Simulation Debriefing from Sim expert Danielle Hart

St Emlyn’s – A great blog on real world Debriefing from Natalie May – not specific to simulation, but incredibly applicable to In Situ sim.

MobileSim – Excellent blog resource on Debriefing with a great structured approach to In Situ Sim debrief

Injectable Orange – Debriefing: a little carrot, a little stick – blog with quick beginners guide tips for debrief.


In Situ Simulation Resources for Quality Improvement

MobileSim –  MobileSim (Jon Gatward’s excellent in situ simulation website including guides, templates and scenarios

INTENSIVE – ICU-IS-SIM (resources for the in situ simulation program at The Alfred ICU, including scenarios)

EMSimCases – EM Sim Cases(ever growing repository of free peer-reviewed simulation cases)

SMACCDUB – Leave the Sim Lab Behind Workshop Scenario Template (Template optimised for In Situ Simulation)