A gap existed between physicians' perceptions and performance of pain, agitation-sedation and delirium assessments in Chinese intensive care units

Kai Chen, Yan-Lin Yang, Hong-Liang Li, Dan Xiao, Yang Wang, Linlin Zhang, Jian-Xin Zhou, Kai Chen, Yan-Lin Yang, Hong-Liang Li, Dan Xiao, Yang Wang, Linlin Zhang, Jian-Xin Zhou

Abstract

Background: Pain, agitation-sedation and delirium management are crucial elements in the care of critically ill patients. In the present study, we aimed to present the current practice of pain, agitation-sedation and delirium assessments in Chinese intensive care units (ICUs) and investigate the gap between physicians' perception and actual clinical performance.

Methods: We sent invitations to the 33 members of the Neuro-Critical Care Committee affiliated with the Chinese Association of Critical Care Physicians. Finally, 24 ICUs (14 general-, 5 neuroscience-, 3 surgical-, and 2 emergency-ICUs) from 20 hospitals participated in this one-day point prevalence study combined with an on-site questionnaire survey. We enrolled adult ICU admitted patients with a length of stay ≥24 h, who were divided into the brain-injured group or non-brain-injured group. The hospital records and nursing records during the 24-h period prior to enrollment were reviewed. Actual evaluations of pain, agitation-sedation and delirium were documented. We invited physicians on-duty during the 24 h prior to the patients' enrollment to complete a survey questionnaire, which contained attitude for importance of pain, agitation-sedation and delirium assessments.

Results: We enrolled 387 patients including 261 (67.4%) brain-injured and 126 (32.6%) non-brain-injured patients. There were 19.9% (95% confidence interval [CI]: 15.9-23.9%) and 25.6% (95% CI: 21.2-29.9%) patients receiving the pain and agitation-sedation scale assessment, respectively. The rates of these two types of assessments were significantly lower in brain-injured patients than non-brain-injured patients (p = 0.003 and < 0.001). Delirium assessment was only performed in three patients (0.8, 95% CI: 0.1-1.7%). In questionnaires collected from 91 physicians, 70.3% (95% CI: 60.8-79.9%) and 82.4% (95% CI: 74.4-90.4%) reported routine use of pain and agitation-sedation scale assessments, respectively. More than half of the physicians (52.7, 95% CI: 42.3-63.2%) reported daily screening for delirium using an assessment scale.

Conclusions: The actual prevalence of pain, agitation-sedation and delirium assessment, especially delirium screening, was suboptimal in Chinese ICUs. There is a gap between physicians' perceptions and actual clinical practice in pain, agitation-sedation and delirium assessments. Our results will prompt further quality improvement projects to optimize the practice of pain, agitation-sedation and delirium management in China.

Trial registration: ClinicalTrials.gov, identifier NCT03975751 . Retrospectively registered on 2 June 2019.

Keywords: Analgesia; Critical care; Practice; Prevalence; Sedation; Survey.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Patients flow chart
Fig. 2
Fig. 2
The primary diagnoses of enrolled patients
Fig. 3
Fig. 3
Prevalences of analgesia and agitation/sedation assessments and administrations. Data are shown as percentages. The prevalence of pain assessment using scale instruments were 19.9% (95% CI: 15.9–23.9%) (panel a). In patients receiving pain assessment (n = 77), four scales were used including VAS (n = 32, 41.6%), CPOT (n = 29, 37.7%), FPS (n = 14, 18.2%) and NRS (n = 2, 2.6%). The rate of pain assessment was significantly lower in brain-injured patients than non-brain-injured patients (p = 0.003). The prevalence of agitation/sedation assessment using scale instruments were 25.6% (95% CI: 21.2–29.9%) (panel b). In patients receiving agitation/sedation assessment (n = 99), three scales were used including RASS (n = 78, 78.8%), SAS (n = 12, 12.1%) and Ramsay scale (n = 9, 9.1%). The rate of agitation/sedation assessment was significantly lower in brain-injured patients than non-brain-injured patients (p < 0.001). The rate of administration of intravenous opioids was 24.3% (95% CI: 20.0–28.6%) (panel c). In patients receiving analgesics (n = 94), six opioids were administered including sufentanil (n = 32, 34.0%), fentanyl (n = 20, 21.3%), dezocine (n = 20, 21.3%), remifentanil (n = 14, 14.9%), butorphanol (n = 7, 7.4%) and morphine (n = 1, 1.1%). The use of opioids was less frequently in brain-injured patients than in non-brain-injured patients (p < 0.001). The rate of sedatives administration was 29.7% (95% CI: 25.1–34.3%) (panel d). In patients receiving sedatives (n = 115), midazolam, propofol, dexmedetomidine, midazolam combined with dexmedetomidine, and propofol combined with dexmedetomidine were used in 53 (46.1%), 31 (27.0%), 23 (20.0%), 5 (4.3%), and 3 (2.6%) patients, respectively. The use of sedatives was significantly less in brain-injured patients than in non-brain-injured patients (p < 0.001). The combination of opioids and sedatives was 18.3% (95% CI: 14.5–22.2%), which was administered less frequently in brain-injured patients than in non-brain-injured patients (p < 0.001, panel e)
Fig. 4
Fig. 4
RASS, SAS and Ramsay scores in patients receiving agitation/sedation assessment. Data are shown as individual points with median, interquartile range and range. A total of 99 patients received agitation/sedation evaluation with 47 and 52 in the brain-injured and non-brain-injured groups, respectively. The RASS (n = 78, 78.8%) was the most frequently used tool. The RASS score was significantly higher in the non-brain-injured group (0 [− 1 − + 1]) than that in the brain-injured group (− 2 [− 4–0], p < 0.001)
Fig. 5
Fig. 5
Rate of assessment of pain and agitation-sedation in brain-injured patients (n = 261) admitted to neuro-ICUs (n = 83) and other types of ICUs (n = 178). Compared to patients admitted to other types of ICUs, pain assessment was performed more often (21.7% vs. 12.4%, p = 0.05) but agitation-sedation assessment was performed less often (9.6% vs. 21.3%, p = 0.02) in patients admitted to neuro-ICUs
Fig. 6
Fig. 6
Cumulative doses of opioids and sedatives used during 24 h prior to on-site investigation in brain-injured and non-brain-injured patients. Data are presented as individual values and median with interquartile range

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