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Outcomes/Prediction Implementation of a protocol for integrated management of pain, agitation, and delirium can improve clinical outcomes in the intensive care unit: A randomized clinical trial Parisa Mansouri, MSc  a , Shoh reh Javadpour , MSc  b , Farid Zand, MD  c, ⁎, Fariba Ghodsbin, MSc  d , Golnar Sabetian, MD  c , Mansoor Masjedi, MD  c , Hamid Reza Tabatabaee, MS  e a Medical-Surgical Nursing Group, Fatemeh Nursing and Midwifery School, Shiraz University of Medical Sciences, Shiraz, Iran b Faculty of Nursing, Jahrom University of Medical Sciences, Jahrom, Iran c Shiraz Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran d Fatemeh Nursing and Midwifery School, Shiraz University of Medical Sciences, Shiraz, Iran e Department of Epidemiology, Shiraz University of Medical Sciences, Shiraz, Iran a b s t r a c t a r t i c l e i n f o Keywords: Agitation Analgesia Critical care medicine Delirium Pain Protocols Sedation Background: Inappropriate diagnosis and treatment of pain, agitation, and delirium (PAD) in intensive care settings results in poor patient outcomes. We designed and used a protocol for systematic assessment and management of PAD by the nurses to improve clinical intensive care unit (ICU) outcomes. Materials and Methods: A tot al of 201patie ntsadmit tedto 2 mix ed medi cal -su rgi calICUs wer e ran domly all oca ted to protocol and control groups. A multidisciplinary team approved the protocol. Pain was assessed by Numerical Ratin g Scaleand Behav ioura l PainScale, agita tionby Richmo nd Agita tionSedation Scale , and deliri um by Confu sion Assessment Method in ICU. The Persian version of the scales was prepared and tested for validity, reliability, and fea sib ili ty in a pre limina ry stu dy. Thepatie ntsin theproto colgroup were manage d pha rma col ogi cal ly acc ord ingto the protocol, whereas those in the control group were managed according to the ICU routine. Results: The median (interquartile range) for the duration of mechanical ventilation in the protocol and control groups was 19 (9.3-67.8) and 40 (0-217) hours, respectively (P  = .038). The median (interquartile range) len gthof ICUstaywas 97 (54.5-189) hoursin theprot oco l gro up vs 170(80-4 08)hour s in thecont rolgrou p ( P b .001). The mortality rate in the protocol group was signicantly reduced from 23.8% to 12.5% ( P  = .046). Conclusion: The curre nt randomized trial provi ded evid ence for a subs tant ial reduc tionin the durat ionof need to ventilato ry support, length of ICU stay, and mortality rates in ICU-admit ted patients through protocol-d irected management of PAD. © 2013 Elsevier Inc. All rights reserved. 1. Introduction Pain is considered a dominant stressor and a main concern to critically ill patients admitted in the intensive care unit (ICU) with a qui te hig h pre val enc e of 50%in med ica l and sur gic al pat ients [1,2], ye t it is a poorly dened entity parti cular ly beca use of its subj ecti ve nature, which can only be truly reported by the individual who is expe rien cing it. MostICU-admitted patie nts are incap able of repor ting their pain because of low level of consci ous nes s, mechanica l ventilatio n, neuro muscular bloc kage, or deep sedation  [3]. Mean- while, there is al way s concer n over the devel opment of dru g depe ndenc y to pain- cont roll ing medi catio ns, whic h creat es grea t stress for the patients, their families, and health care staff  [4]. Uncontrolled pain can have harmful effects on the function of different body systems, most notable of which are cardiovascular, resp irato ry, musc ulosk eletal, and, above all, menta l func tion  [5]. Several studies havedemonstrated slee p depri vation, fatig ue, anxi ety, agitation, delirium, and increase in undesirable incidents such as self- extubation as the mental consequences of inadequate pain treatment [6,7]. The ultimate goal for pain management is producing pain-free calm patients [8]  and therefore reducing pain-mediated agitation or delirious episodes. Poor pain control also results in severe agitation and further complicates the patient's condition. There are substantial consequences to inadequate control of pain and agitation such as aggressive behavior, self-removal of important tubes and catheters, and patient-ventilator asynchrony [9]. Agita tion is usual ly treat ed by administr ation of seda tives to reduce patient's awareness to a suf cient level and induce amnesia. An inherent risk of agita tion treatment is prolo nged or exce ssiv e sedation, which signicantly compromises caregivers' control over patient's level of consciousness and increases the duration of ICU stay [10]. Ther efor e, the optimal goal in agitation treatment would be  Journal of Critical Care 28 (2013) 918–922 ⁎  Corresponding author. Shiraz Anesthesiology and Critical Care Research Center, Shiraz Univer sity of Medic al Sciences, Shiraz, Iran. Tel.: +98 917 313 3806; fax: + 98 711 647 4270. E-mail address:  [email protected] (F. Zand). 0883-9441/$  – see front matte r © 2013 Elsevier Inc. All right s reserv ed. http://dx.doi.org/10.1016/j.jcrc.2013.06.019 Contents lists available at  ScienceDirect  Journal of Critical Care  j o u r na l h omep a ge:  www.jccjournal.org

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