Common Challenges to Effective ABCDEF Bundle Implementation: The ICU Liberation Campaign Experience.

Although growing evidence supports the safety and effectiveness of the ABCDEF bundle (A, assess, prevent, and manage pain; B, both spontaneous awakening and spontaneous breathing trials; C, choice of analgesic and sedation; D, delirium: assess, prevent, and manage; E, early mobility and exercise; and F, family engagement and empowerment), intensive care unit providers often struggle with how to reliably and consistently incorporate this interprofessional, evidence-based intervention into everyday clinical practice. Recently, the Society of Critical Care Medicine completed the ICU Liberation ABCDEF Bundle Improvement Collaborative, a 20-month, nationwide, multicenter quality improvement initiative that formalized dissemination and implementation strategies and tracked key performance metrics to overcome barriers to ABCDEF bundle adoption. The purpose of this article is to discuss some of the most challenging implementation issues that Collaborative teams experienced, and to provide some practical advice from leading experts on ways to overcome these barriers.

American Society for Pain Management Nursing Position Statement: Prescribing and Administering Opioid Doses Based Solely on Pain Intensity.

The foundation of safe and effective pain management is an individualized, comprehensive pain assessment, which includes, but is not limited to, determining the intensity of pain if the patient is able to report it. An unforeseen consequence of the widespread use of pain intensity rating scales is the practice of prescribing specific doses of opioid analgesics based solely on specific pain intensity. Many factors in addition to pain intensity influence opioid requirements, and there is no research showing that a specific opioid dose will relieve pain of a specific intensity in all patients.

Avoiding Adverse Events Secondary to Opioid-Induced Respiratory Depression: Implications for Nurse Executives and Patient Safety.

Background: Guidelines with recommendations for monitoring type and timing of hospitalized patients for opioid-induced respiratory depression have been published, yet adverse events continue to occur.

Objective: This study reports on the monitoring practices of 8 hospitals that volunteered to pilot test a Centers for Medicare & Medicaid Services e-quality measure that was under development. Recommendations for nurse executives are provided to support patient safety.

Unconventional use of a PCA pump: nurse-activated dosing.

Creative approaches, such as NAD, can be taken to manage pain in patients who would be candidates for PCA therapy if they were physically and cognitively able to manage their own pain. NAD authorizes the patient's primary nurse to administer bolus doses with or without a basal rate via the PCA infusion pump. Doses are administered for breakthrough pain with a basal rate or in scheduled doses to maintain analgesia without a basal rate.

Practice recommendations for pain assessment by self-report with African American older adults.

Despite decades of education and clinical practice guidelines underscoring disparities in pain management, pain continues to be inadequately managed in older African American adults as a result of patient, provider, and systems factors. Critical factors influencing pain assessment in older African American adults has not been extensively examined, contributing to a lack of data to inform health care providers' knowledge on culturally-responsive pain assessment in older African Americans. Assessing pain in older African Americans is unique because differences in language, cultural beliefs, and practices moderate how they report and express pain.

Instituting best practice for monitoring for opioid-induced advancing sedation in hospitalized patients.

Background: Adverse events related to opioid-induced unintended advancing sedation and respiratory depression in hospitalized patients are occurring with increased frequency, and these adverse events can have a negative impact on quality and cost outcomes.

Aim: The goal of this paper is to inform nurses on best practices for preventing opioid-induced advancing sedation and respiratory depression, and to inform nurse leaders on implementation strategies to guide change in policies and practice.

Methods: This paper presents an evidenced-based systematic approach for organizations to use in implementing strategies to reduce adverse events secondary to opioid-induced advancing sedation and respiratory depression in the hospitalized adult patient.

The role of intravenous acetaminophen in acute pain management: a case-illustrated review.

For more than a century, acetaminophen has been recognized worldwide as a safe and effective agent for relieving pain and reducing fever in a wide range of patients. However, until recently, acetaminophen was available in the United States only in oral and rectal suppository formulations. In November 2010, the United States Food and Drug Administration granted approval for the use of a new intravenous (IV) formulation of acetaminophen for: 1) the management of mild to moderate pain; 2) the management of moderate to severe pain with adjunctive opioid analgesics; and 3) the reduction of fever in adults and children (age ≥ 2 years).

American Society for Pain Management Nursing guidelines on monitoring for opioid-induced sedation and respiratory depression.

As the complexity of analgesic therapies increases, priorities of care must be established to balance aggressive pain management with measures to prevent or minimize adverse events and to ensure high quality and safe care. Opioid analgesia remains the primary pharmacologic intervention for managing pain in hospitalized patients. Unintended advancing sedation and respiratory depression are two of the most serious opioid-related adverse events.