(923) Implementation of a Behavioral Pain Scale to Improve Opioid Utilization in the Critical Care Setting

Introduction: Opioids and sedatives are the standard of care for treatment of analgesia and agitation for patients receiving mechanical ventilation. PADIS Guidelines recommend analgosedation while minimizing exposure to these medications while sustaining light sedation and patient comfort. While guidelines recommend these strategies, there is limited data available assessing how to implement into daily clinical practice. In an effort to strive for the most appropriate utilization of these medications, we initiated a two phase approach to implement the Critical Care Pain Observation Tool (CPOT) assessment into our ICUs and into analgesic orders.

Methods: In May 2022 the CPOT was added to our healthcare system’s electronic medical record (EMR) as part of the ICU Liberation Bundle. Phase one included education regarding how to perform the assessment, how often to assess and document, instruction to assess and treat pain prior to assessment and treatment of agitation, and how to incorporate the assessment into daily patient care. Phase two included an update to opioid orders to be administered for CPOT scores of 3 or greater. The change to orders was implemented August 2023. Assessments were completed after each phase.

Results: A total of 150 patients were included in the study (50 pre-CPOT education, 50 post-CPOT education, and 50 CPOT in orders). Phase one results comparing the pre- and post-CPOT education groups did not show statistically significant reductions across all outcomes: average daily opioid dose in fentanyl equivalents, average daily doses of propofol, dexmedetomidine, and midazolam, mean hospital and ICU LOS, or mean ventilator days. Phase two results comparing pre-CPOT education with post-CPOT in orders, showed reductions in mean daily opioid dose in fentanyl equivalents (4,914.801 vs 1,316.901 mcg, p=0.0374, 95% CI [214.943 to 6980.864]), mean hospital LOS (14.659 vs 8.7692 days, p=0.0039, 95% CI [1.936 to 9.843]), mean ICU LOS (9.2086 vs 4.5845 days, p=0.003, 95% CI [2.204 to 7.044]), mean daily dexmedetomidine dose (705.3806 vs 142.1445 mcg, p=0.0488, 95% CI [3.076 to 1123.397]).

Conclusions: Targeted education of the CPOT assessment in combination with incorporating the tool into opioid orders demonstrated improved length of stay, medication utilization, and ventilator days.