Implementing the 2013 PAD guidelines: top ten points to consider

Semin Respir Crit Care Med. 2013 Apr;34(2):223-35. doi: 10.1055/s-0033-1342985. Epub 2013 May 28.


It has been 10 years since the last publication of the clinical practice guidelines for pain, agitation/sedation, and delirium (PAD). The results of new studies have directed significant changes in critical care practice. Using the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) methodology, the guidelines were revised, resulting in 32 recommendations and 22 summary statements. This article provides guidance toward guideline implementation strategies and outlines 10 key points to consider. Compared with its predecessor, the 2013 PAD guidelines are less prescriptive in that they recommend approaches to patient care rather than giving specific medication recommendations. This will help focus care teams on the process and structure of patient management and result in more flexibility when choosing specific medications. This article outlines approaches to guideline implementation that take into account the changes in philosophy surrounding medication selection. The manuscript focuses on the areas anticipated to generate the most change such as lighter sedation targets, avoidance of benzodiazepines, and early mobility. A gap analysis grid is provided. The release of any guideline should prompt reevaluation of current institutional practice standards. This manuscript uses the PAD guidelines as an example of how to approach the interprofessional work of guideline implementation.

MeSH terms

  • Critical Care / methods
  • Delirium / etiology
  • Delirium / therapy*
  • Humans
  • Intensive Care Units
  • Pain Management / methods*
  • Patient Care / methods
  • Practice Guidelines as Topic*
  • Psychomotor Agitation / etiology
  • Psychomotor Agitation / therapy*