title: 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.
abstract: 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.
  
  
  METHODS
  A total of 201 patients admitted to 2 mixed medical-surgical ICUs were randomly allocated to protocol and control groups. A multidisciplinary team approved the protocol. Pain was assessed by Numerical Rating Scale and Behavioural Pain Scale, agitation by Richmond Agitation Sedation Scale, and delirium by Confusion Assessment Method in ICU. The Persian version of the scales was prepared and tested for validity, reliability, and feasibility in a preliminary study. The patients in the protocol group were managed pharmacologically according to 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) length of ICU stay was 97 (54.5-189) hours in the protocol group vs 170 (80-408) hours in the control group (P < .001). The mortality rate in the protocol group was significantly reduced from 23.8% to 12.5% (P = .046).
  
  
  CONCLUSIONS
  The current randomized trial provided evidence for a substantial reduction in the duration of need to ventilatory support, length of ICU stay, and mortality rates in ICU-admitted patients through protocol-directed management of PAD.
authors.affiliation: Medical-Surgical Nursing Group, Fatemeh Nursing and Midwifery School, Shiraz University of Medical Sciences, Shiraz, Iran.
authors.forename: Parisa
authors.initials: P
authors.lastname: Mansouri
authors.forename: Shohreh
authors.initials: S
authors.lastname: Javadpour
authors.forename: Farid
authors.initials: F
authors.lastname: Zand
authors.forename: Fariba
authors.initials: F
authors.lastname: Ghodsbin
authors.forename: Golnar
authors.initials: G
authors.lastname: Sabetian
authors.forename: Mansoor
authors.initials: M
authors.lastname: Masjedi
authors.forename: Hamid Reza
authors.initials: HR
authors.lastname: Tabatabaee
mesh_terms: D018806:APACHE; D002985:Clinical Protocols; D003693:Delirium / Q000188:drug therapy / Q000451:nursing*; D005260:Female; D006801:Humans; D007362:Intensive Care Units; D007492:Iran; D008297:Male; D008875:Middle Aged; D009730:Nursing Assessment; D017063:Outcome Assessment, Health Care; D059408:Pain Management / Q000451:nursing*; D010147:Pain Measurement; D011595:Psychomotor Agitation / Q000188:drug therapy / Q000451:nursing*; D015203:Reproducibility of Results; D012121:Respiration, Artificial
keywords: Agitation; Analgesia; Critical care medicine; Delirium; Pain; Protocols; Sedation