Patient Safety Tip of the Week

October 29, 2013

PAD: The Pain, Agitation, and Delirium Care Bundle



We have done multiple columns on the prevention and management of delirium in the ICU (and elsewhere) and the integration of such approaches with other intervention programs in the ICU (see the list at the end of today’s column). We’ve also done multiple columns discussing ICU interventions that improve time on ventilators, ICU length of stay, etc. Our December 2010 What’s New in the Patient Safety World column “The ABCDE Bundle” discussed one such bundle, the “ABCDE bundle” (Vasilevskis 2010). The ABCDE acronym stands for “Awakening and Breathing Coordination”, “Delirium monitoring”, and “Exercise/Early mobility”.


In January 2013 the American College of Critical Care Medicine published new guidelines on the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit (Barr 2013a). We’ll refer to these as PAD. The guidelines were developed after a comprehensive review of the literature to determine evidence-based best practices for prevention and management of pain, agitation and sedation, and delirium in ICU patients. The released guidelines apply to adult patients and there is a separate guideline in the works for pediatric patients.


An entire recent supplement of Critical Care Medicine was dedicated to “Creating and Implementing the 2013 ICU Pain, Agitation, and Delirium Guidelines for Adult ICU Patients” and related issues. One of the papers in that supplement discusses the synergistic benefits of implementing the PAD guidelines in conjunction with other ICU strategies like spontaneous awakening trials, spontaneous breathing trials, early mobility programs, and sleep hygiene programs (Barr 2013b).


PAD uses validated tools to regularly assess ICU patients regarding pain, agitation/sedation, and delirium. Results of the assessments are recorded in the medical record and are incorporated into the daily discussions on interdisciplinary ICU rounds, with ICU teams discussing each individual patient’s scores and regimens, the current and target scores, and then incorporated into a treatment plan for each individual patient.


For pain, a numerical rating scale (NRS) is used for patients who are communicative. For those unable to communicate pain, use of a behavioral pain scale (BPS) or the Critical-Care Pain Observation Tool (CPOT) is recommended. The PAD mandates that assessments for pain using these tools be done at least 4 times per nursing shift (more often if necessary) and the results documented in the medical record.


For agitation/sedation PAD determined that the RASS (Richmond Agitation-Sedation Scale) or the SAS (Sedation-Agitation Scale) are the most valid and reliable assessment tools. These are also done at least 4 times per nursing shift (more often if necessary).


For delirium, the CAM-ICU or the ICDSC (Intensive Care Delirium Screening Checklist) are recommended as the most valid and reliable monitoring tools. These are done at least every nursing shift and more often if necessary.


Pain management is usually considered first, particularly since it has a big impact on management of the other conditions. If pain control is optimized it may reduce the need for sedation. Similarly, pain is one of the common contributing factors to delirium. They cite several studies showing that an “analgesia first” approach (minimizing the need for sedation) is associated with reductions in duration of mechanical ventilation and shorter ICU lengths of stay. It notes that pain is not just seen in surgical ICU patients but that medical patients frequently have pain in the ICU. Procedure-related pain is common and should be managed pre-emptively. PAD calls for prompt management of pain (within 30 minutes of its recognition) and pain should be assessed again 30 minutes after an intervention to assess efficacy of that intervention.


While PAD is generally nonproscriptive regarding specific medications, it does recommend opiates as the first line therapy for non-neuropathic pain (though it notes that adjunctive drugs such as NSAID’s or acetaminophen may be used to help lower the dose of opioids). PAD recommends gabapentin or carbamazepine for neuropathic pain. They suggest that neuraxial analgesia be restricted to those with rib fractures and certain abdominal procedures.


Sedation should be used only as needed. If pain is adequately managed many patients may need no sedation at all. We all recognize there is a tendency to oversedate ICU patients on ventilators (see also our March 2010 What’s New in the Patient Safety World column “If Sedation Vacations Work, Why Not Eliminate Sedation All Together?”). And when sedation is needed it should be titrated to a light level where the patient is able to maintain interaction with his surroundings and follow simple commands. They note that light sedation could be achieved by either targeted sedation strategies or by daily sedation holidays. Again, they are not proscriptive regarding specific medication recommendations though they do note that “there is a growing body of evidence that the use of IV benzodiazepines for sedation of ICU patients, specifically midazolam and lorazepam, is associated with worse ICU outcomes than sedation with nonbenzodiazepines (specifically propofol and desmedetomidine)”. They discuss integration of the PAD interventions with other interventions like spontaneous breathing trials, spontaneous awakening trials, and daily sedation interruptions.


Management of delirium starts with removing many of the potential contributing factors we have often discussed (certain medical conditions, preexisting cognitive deficits, withdrawal states, untreated pain, sedating drugs, sleep deprivation, restraints, Foley catheters, immobilization, etc.). If the delirium persists despite removal of such factors they recommend nonpharmacological interventions like reorienting activities, ensuring patients have their eyeglasses and hearing aids, maintaining sleep-wake cycles, and early mobilization. They have a good discussion of ways to promote sleep in the ICU, including clustering of ICU patient care activities to minimize frequent patient arousals. Controlling light and noise are important. They recommend raising the window blinds during the daytime, avoiding excessive daytime naps, minimizing caffeine use in the evening, and use of earplugs. Early mobilization is encouraged, getting the patient up out of bed even while being mechanically ventilated.


They summarize the conflicting literature on use of both traditional and atypical antipsychotic drugs and really make no recommendation regarding their use (see also our September 2013 What’s New in the Patient Safety World column “Disappointing Results in Delirium”).


The authors go on to present data demonstrating that there appear to be synergistic effects from implementing multiple components of not only the PAD bundle but also the other interventions noted above. The results show benefits in both patient outcomes and overall costs. Importantly, the authors note that there is an evidence base supporting improved outcomes from the various interventions individually and in combination but that, to date, there is no measurement of outcomes from implementation of the entire PAD program.


Regarding implementation strategies, they stress that implementing the assessment tools first and demonstrating these are done reliably and consistently is important. Those assessments should be incorporated into daily ICU rounds, ICU goal sheets, checklists, order sets and the overall patient care plan.


The PAD guidelines are very promising and the early experiences seem to have been quite positive. However, we look forward to seeing results of studies that demonstrate improved outcomes and lower costs after implementation of the entire PAD bundle, with or without intergration with the other strategies. Recall a lesson in our December 2010 What’s New in the Patient Safety World column “Bad Bundle? Or Not?”: don’t assume that interventions which are combined will necessarily produce more improvement. That column discussed a randomized controlled trial of a bundle of interventions in colorectal surgery that had been shown to reduce surgical site infections in studies where they were evaluated individually (Anthony 2010). They went into their study expecting to see at least an additive and perhaps synergistic effect of combining interventions. It is counterintuitive to think that combining interventions that proven efficacy individually would actually lead to worse outcomes. But that is exactly what they saw in their study.


Nevertheless, the PAD guidelines are practical and have a sound evidence base and it makes a whole lot of sense to implement them in your ICU’s even while we are awaiting confirmation of their collective efficacy.



Some of our prior columns on delirium assessment and management:

·         October 21, 2008 “Preventing Delirium

·         October 14, 2009 “Managing Delirium

·         February 10, 2009 “Sedation in the ICU: The Dexmedetomidine Study

·         March 31, 2009 “Screening Patients for Risk of Delirium

·         June 23, 2009  More on Delirium in the ICU

·         January 26, 2010 “Preventing Postoperative Delirium

·         August 31, 2010 “Postoperative Delirium

·         September 2011 “Modified HELP Helps Outcomes in Elderly Undergoing Abdominal Surgery”)

·         December 2010 “The ABCDE Bundle

·         February 28, 2012AACN Practice Alert on Delirium in Critical Care

·         April 3, 2012 “New Risk for Postoperative Delirium: Obstructive Sleep Apnea

·         August 7, 2012 “Cognition, Post-Op Delirium, and Post-Op Outcomes

·         September 2013 “Disappointing Results in Delirium







Vasilevskis EE, Ely EW,  Speroff T, et al. Reducing Iatrogenic Risks: ICU-Acquired Delirium and Weakness—Crossing the Quality Chasm. Chest 2010; 138: 1224-1233   November 2010



Barr J, Fraser GL, Puntillo K, et al. Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit. Critical Care Medicine 2013; 41(1): 263–306



Critical Care Medicine Supplement. Creating and Implementing the 2013 ICU Pain, Agitation, and Delirium Guidelines for Adult ICU Patients. Critical Care Medicine 2013; 41(9) (Supplement 1): S1-S145 September 2013



Barr J, Pandharipande PP. The Pain, Agitation, and Delirium Care Bundle: Synergistic Benefits of Implementing the 2013 Pain, Agitation, and Delirium Guidelines in an Integrated and Interdisciplinary Fashion. Critical Care Medicine 2013; 41(9): S99-S115,_Agitation,_and_Delirium_Care_Bundle__.9.aspx



Anthony T, Murray BW, Sum-Ping JT, et al. Evaluating an Evidence-Based Bundle for Preventing Surgical Site Infection. A Randomized Trial. Arch Surg. Published online November 15, 2010. doi:10.1001/archsurg.2010.249










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