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

J Crit Care. 2013 Dec;28(6):918-22. doi: 10.1016/j.jcrc.2013.06.019. Epub 2013 Sep 4.


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.

Materials and 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).

Conclusion: 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.

Keywords: Agitation; Analgesia; Critical care medicine; Delirium; Pain; Protocols; Sedation.

Publication types

  • Multicenter Study
  • Randomized Controlled Trial

MeSH terms

  • Clinical Protocols*
  • Delirium / drug therapy
  • Delirium / nursing*
  • Female
  • Humans
  • Intensive Care Units*
  • Iran
  • Male
  • Middle Aged
  • Nursing Assessment*
  • Outcome Assessment, Health Care*
  • Pain Management / nursing*
  • Pain Measurement
  • Psychomotor Agitation / drug therapy
  • Psychomotor Agitation / nursing*
  • Reproducibility of Results
  • Respiration, Artificial