12/9/2015. Working in the Intensive Care Unit Be Both Researcher and Clinician. Why Data Collection is Worth the Time

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1 Improving and Sustaining ICU Physical Rehabilitation with Data Collection and Evidence APTA CSM Anaheim, CA February 20, 2016 Heidi Engel, PT, DPT University of California San Francisco (UCSF) Amy Nordon Craft, PT, DSc University of Colorado, Denver Amy Pastva, PT, PhD, Duke University School of Medicine John Lowman, PT, PhD, University of Alabama Conflict of Interest Disclosure Heidi Engel, PT, DPT receives grant money through the Gordon and Betty Moore Foundation for Project Emerge at UCSF Reducing 7 Harms in Critical Care Heidi Engel, PT, DPT has been a paid consultant for the Arjo Huntleigh Medical Equipment Company Learning Objectives 1. Convey the performance of data collection to achieve targets set for process and outcomes improvements relating to ICU early mobilization 2. Explain methods for quality improvement initiatives for ICU early mobility 3. Describe the opportunities for Physical Therapist initiated clinical improvements through research in ICU early mobility 4. Report on the APTA sponsored clinical practice guideline development process in progress for PT practice in the ICU 1

2 Working in the Intensive Care Unit 2015 What is the role for the Physical Therapist? Are we necessary? The impact of our interventions? Part of the team? Be Both Researcher and Clinician In our Brazilian ICU, mobilization therapy in critically ill patients was safe and feasible; however, similar to other countries, in bed exercises were the most prevalent activity. During mechanical ventilation, only a small percentage of activities involved standing or mobilizing away from the bed. Pires Neto RC, Lima NP, Cardim GM, Park M, Denehy L: (2015). Why Data Collection is Worth the Time Know Your Patients, Understand your Colleagues Dedication to helping the patients you will never meet Research makes you a better clinician, Being a clinician makes you a more effective researcher, and you can keep it simple Ohtake PJ, Strasser DC, Needham DM: (2013). 2

3 KEY REFERENCES: ICU acquired weakness and cognitive deficits: occur quickly and resolve slowly Herridge M. N Engl J Med. 2003;348: De Jonghe B. Crit Care Clin. 2007;23: Levine S. N Engl J Med. 2008;358: Herridge M. N Engl J Med. 2011;364: Grosu H. Chest. 2012;142: Puthucheary Z. JAMA. 2013;310: Calvo Ayala E. Chest. 2013;144: Kress J. N Engl J Med. 2014;370: Fan E. Am JRespir Crit Care Med. 2014;190: Pandharipande P. N Engl J Med. 2013;369: Outcomes from ICU Mobility QI Projects Decrease ICU and hospital LOS Improve overall physical functioning Decrease duration of mechanical ventilation Decrease incidence of delirium Decreased need for tracheotomies Greater ability to discharge to home rather than SNF Bailey P. Crit Care Med Jan;35(1): Morris PE. Crit Care Med Aug;36(8): Schweickert WD. Lancet May ; 373: QI Projects by Comparison QI Projects in ICU Early Mobility Objective Planning/ Pre- intervention time frame Intervention Wake Forest N = 165 Reduce Weakness, immobility with early PT Multi-disciplinary group (time frame?) Intensive care mobility team (Critical care nurse, nursing assistant, physical therapist) initiate mobility protocol within 48hrs of admission Johns Hopkins N = 27 Provide early PM&R in the ICU UCSF N = year 1.5 years Increase early ICU mobilization using 4 step (4Es) model: 1. Summarize evidence 2. Identify barriers 3. Establish performance measures 4. Ensure patients receive intervention Provide earlier & more frequent PT in the ICU ICU early mobilization group established guidelines to mobilize pts in the ICU, with a goal of initiating PT within 48 hours of admission to ICU 3

4 QI Projects by Comparison QI Projects in ICU Early Mobility Objective Outcomes Measured Wake Forest N = 165 Reduce Weakness, immobility with early PT Number of patients receiving physical therapy First day out of bed Frequency of therapy Number of days in ICU Number of days in hospital Johns Hopkins N = 27 Provide early PM&R in the ICU Proportion of ICU days with no therapy PT and OT consultations, proportion patients Alert during sedation assessment Physiological stability, Unexpected events, proportion of treatments Functional Mobility: proportion of treatments sitting edge of bed or higher level activities MICU LOS Total Hospital LOS UCSF N = 179 Provide earlier & more frequent PT in the ICU Number of days to initiating PT (median) ICU LOS median days Hospital LOS median days Distance walked in ICU (median ft) Percentage of pts discharged to home Level of assistance (ICF) Percentage of pts ambulating QI Project Example Objective: Seek adoption of new practice patterns, translate evidence based knowledge into practice, is your institution ready for change? Utilizing the CFIR framework Consolidated Framework for Implementation Research To examine the intervention, inner setting, outer setting, individuals involved, and process to accomplishing intervention Example: Intervention characteristics of how specific and adaptable is the intervention? Inner setting of work load and staffing ratios in ICU, outer setting of Administrative support, self efficacy of individuals, educational processes for implementation, evaluative surveys as follow up Balas MC, Burke WJ, Gannon D, Cohen MZ, Colburn L, Bevil C, Franz D, Olsen KM, Ely EW, Vasilevskis EE (2013). Outcomes Cost Decreased cost for protocol group $6,805,082 vs. $7,309,871 Attributed to decreased ICU and hospital LOS Morris PE, Goad A, Thompson C, Taylor K, Harry B, Passmore L, Ross A, Anderson L, Baker S, Sanchez M et al: Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med 2008, 36(8): Utilize administrative champions to make financial modeling Lord RK, Mayhew CR, Korupolu R, Mantheiy EC, Friedman MA, Palmer JB, Needham DM (2013). 4

5 Institute for Healthcare Improvement (IHI) IHI: a not for profit organization based in Cambridge, Massachusetts has led many innovative critical care efforts over the past seventeen years Emphasis on setting individual goals, drawing on strength of local expertise Model for Improvement Plan, Do, Study, Act cycle, small tests of change Lipshutz AK, Fee C, Schell H, Campbell L, Taylor J, Sharpe BA, Nguyen J, Gropper MA (2008). Institute for Healthcare Improvement PDSA Cycle Plan: Critically appraise the literature to select an evidence based initiative. Ensure QI team is interdisciplinary and represents key stakeholders including frontline staff, quality champions, and key executives. Evaluate resources within institution to provide support. Anticipate changes in resource and personnel needs associated with process change; consider the opportunity costs of the initiative. Utilize QI tools to identify opportunities for improvement, including root cause analysis, fishbone diagrams, run charts, Pareto charts, and prioritization matrices. Institute for Healthcare Improvement PDSA Cycle Plan: Identify SMART (specific, measurable, achievable, relevant, timely) goals/targets. Identify a champion of the QI effort in each department or stakeholder group; create a back up plan in the event of unexpected loss of a champion. Perform work flow analyses to assess how the initiative will affect the work environment. Consider pilot testing and stepwise implementation. Design an easy to use measurement tool that is integrated into the work flow and provide incentives for its use. 5

6 Institute for Healthcare Improvement PDSA Cycle Do: Market the practice change with sound evidence provided in a concise format distributed to all stakeholders. Remind clinicians of the process change using signage and compliance monitoring. Communicate goals/targets and the time line for achievement. Consider creating competition among various units to increase motivation and participation. Ensure protocol or process change is effectively incorporated into practice through tools such as order sets: Create standard work. Verify validity of data collection. Study: Re evaluate protocol. Obtain clinician feedback. Society of Critical Care Medicine (SCCM) ICU Liberation Campaign Implementing the entire ABCDEF Bundle is crucial! Awakening and Assessing Pain Breathing Choice of Sedation, Coordination of AB Delirium Early Mobility Family Engagement Balas M. Crit Care Med. 2013;42: Bassett R. Jt Comm J Qual Patient Saf. 2015;41: Klompas M. Am J Respir Crit Care Med. 2015;191: Miller M. Ann Am Thorac Soc. 2015;12: How Early Does This Need to Be? Neurocognitive and Functional Benefits to ICU Patients RCT 104 patients on mechanical ventilation. intervention group PT median of 1.5 days intubation control group PT median of 7.4 days Intervention groupless days of delirium and MV 59% return to independent function at hospital discharge 35% in control group Schweickert WD, Pohlman MC, Pohlman AS, et al. (2009). 6

7 The dilemma of the young male patient Agitated when lying in bed restrained Fully alert able to communicate sitting up with clipboard Daniel CR, Alessandra de Matos C, Barbosa de Meneses J, Bucoski SC, Frez AR, Mora CT, Ruaro JA: (2015). Timeliness of ICU Mobility in 9/13 ICU for Mechanically Ventilated Patients Median for entire vented cohort (N = 78) through Admit to PT Eval 4.3 days Admit to Ambulation 7.9 days Eval to Ambulation 2.1 days Admit to ICU to d/c (LOS) 19.4 days Apache II 24.5 Timeliness of ICU Mobility in 9/13 ICU for Mechanically Ventilated Patients Median for geriatric vented cohort (N=45) through Adm to PT eval 4.2 days Adm to Ambulation 6.5 days Eval to Ambulation 2.0 days Adm to ICU to d/c (LOS) 18.0 days Apache II 25 7

8 Timeliness of ICU Mobility in 9/13 ICU for Mechanically Ventilated Patients Median for young vented cohort (N = 33) through Adm to PT eval 5.2 days Adm to Ambulation 9.2 days Eval to Ambulation 2.5 days Adm to ICU to d/c (LOS) 24.2 days Apache II 20 First Question to Ask: Did Our Patient Walk Today? Staff and culture of the ICU set the expectation Culture consists of automatic behaviors, self directed, the right path (not always the easiest path) is chosen consistently without dictate Patients and families are willing participants Thomsen GE, Snow GL, Rodriguez L, Hopkins RO. (2008). Feasibility of Walking Data from UCSF March 2013 Through August 2013 Mixed Medical Surgical ICU 563 patients admitted for > 48 hrs 382 referred to PT (68%) Median Age of PT Patients Median APACHE ll Score 64 (55,74) IQR 19 (13,25) IQR Walk during their ICU stay 283 PT Patients (74% in PT, 50% of all admits) 8

9 How Are We Doing? Point Prevalence Studies: Nydahl P, Ruhl AP, Bartoszek G, Dubb R, Filipovic S, Flohr HJ, Kaltwasser A, Mende H, Rothaug O, Schuchhardt D et al: (2014) In this 1 day point prevalence study conducted across Germany only 8% of patients with an endotracheal tube were mobilized out of bed as part of routine care. Terri Hough University of Washington Medical Center, Presenting at The 7 th International Physical Medicine and Rehabilitation of Critically Ill Patients Meeting 5/17/2014, Across the US: 64% of ICU patients experienced any activity 50% of those were bed level activity 20% of those were transfers to a chair 10% of those were walking Jolley SE, Dale CR, Hough CL (2015) Barriers to Implementation Nervous or skeptical clinicians Minimal resources allocated Awkward equipment PT referrals still too late Unclear protocol Mobility prior to extubation is difficult concept Rotating and changing personnel Variations in sedation practices New hospital and discharge course predictions required for ICU and floor personnel Pawlik AJ, Kress JP. (2012). Researching the Barriers 5 studies compared: Physiologic instability Sedation level Fear of dislodging lines and tubes Medical procedures Medical orders Patient refusal Resistive or disengaged team members Lack of staffing Staff burden too busy, work load perceived as too heavy Inexperienced staff Lack of equipment Holdsworth C, Haines KJ, Francis JJ, Marshall A, O'Connor D, Skinner EH: (2015). 9

10 Facilitators of Mobility Adequate staffing Dedicated ICU PT/OT Cooperation, flexibility, collaboration of staff Multi discipline rounding A mobility protocol to make new mobility behaviors routine Hemodynamic stability of patient addressed specifically to facilitate mobility Awake and alert patient: target RASS 0 to 1 achieved Bakhru RN, Wiebe DJ, McWilliams DJ, Spuhler VJ, Schweickert WD: (2015). Holdsworth C, Haines KJ, Francis JJ, Marshall A, O'Connor D, Skinner EH: (2015). Case Comparisons 13 ICU standard PT care 51 yo M ARDS pt, I community level activity 50mcg propofol PEEP 8 FiO2.6 Bed rest activity orders, PT referral on HD 10 Failed SBT, delirium LOS 1 month, 5 sessions PT d/c d to acute care able to stand 30 seconds with mina of 2 9 ICU early mobilization 25 yo F ARDS pt, I community level activity 100mcg propofol PEEP 16 FiO2.9 Activity as tolerated orders, PT referral on HD 1 ICUAW, tracheotomy LOS 1 month, 19 sessions PT d/c d to acute rehab able to walk SBA FWW 60 X4 Case Series Demonstrating New Practice MD orders to disconnect patients from CVVH for 2 hours to allow for ambulation. All patients walk 200 or more No adverse events, no loss of CVVH lines or filters 10

11 KEY REFERENCES: Laying the foundation for mobility for femoral catheters PermeC. Cardiopulm Phys Ther J. 2013;24(2): Damluji A J. Crit Care Aug;28(4):535.e9 15 PermeC.. J Acute Care Phys Ther. 2011;2(1): PermeC. Am J Respir Crit Care Med. 2009;179:A1586. What About All Those Critical Lines? Patient lines and drains can be accommodated Including Femoral Lines Mechanical ventilation and CVVH lines Damluji, A., et al. (2013). Winkelman, C. (2011). Patient on Mechanical Ventilation AND CVVH with Femoral Catheter 11

12 What Did our Patient Achieve Today? PHYSICAL THERAPY PROGRESS NOTE This note does not include all documentation from the physical therapy session. For the complete physical therapy documentation, please see the report: PT Adult Day by Day The following documentation is for a: Charting Type: Treatment INPATIENT RECOMMENDATIONS Physical Therapist Global Assessment of Mobility UCSF Mobility Score Defined the Dependent Impaired Patient 0 Nothing/Passive Bed rest, no activity or passive ROM only. Passively rolled or PROM by staff, not actively moving. 1Active bed exercise / Edge of bed sitting < 5 minutes Active bed level exercise including rolling self, lifting hips, cycle ergometry, active ROM. Patient participating in activity. Edge of bed sitting attempted, lasting less than 5 minutes 2 Tilt table positioning/ neuro chair Requires some ability for patient to support self 3 Edge of bed sitting 5 minutes Any level of assistance. Actively sitting on edge of bed with some trunk control 4 Passive transfer to chair (total assist) & maintains sitting in chair Total assist to chair. Patient has trunk control to maintain sitting position in chair. SARA 3000 or ceiling lift transfer to chair. UCSF Mobility Score Defined the Deconditioned Patient 5Active transfer to chair Some level of assistance to chair. Assisted stand and pivot step or shuffle to chair. 6 Standing with assistance < 10 seconds Standing with weight bearing < 10 seconds, some level of assistance or support device (e.g. STEDY) 7 Standing with or without assistance 10 seconds Standing with weight bearing 10 seconds. With or without assistance. May include use of assistive device. 12

13 UCSF Mobility Score Defined the Walking Patient 8 Walking > 5 feet, up to 200 feet Walking away from bed/chair at least 5 feet. Assistive device may be used (or wheelchair mobility). 9Walking 200 feet, up to 400 feet Walking in hall feet. Any device or level of assist (or wheelchair mobility). 10 Walking 400ft Walking in hall 400 feet With or without device, +/ supervision assist (or wheelchair mobility). Opportunities APTA CPG APTA Next Conference for ICU as a Model of care and CPG Results of ICU Liberation mentoring, joint webinar SCCM and APTA UCSF Emerge Project reducing harms with CUSP, PFAC, and technology Abstract for American Thoracic Society due 11/2015 on defining ICU EM as ICU Walking QI for our vented patients next data collection 2016 Creating Competencies for PTs working in the ICU New safe patient handling equipment trials Case Studies, Case Series Can We Do Better? Clinical Outcomes for Survivors of ARDS At One Year (Median age 45, N= 83) 48% returned to work Results of 6 minute walk test are 66% of predicted normal At Five Years (Median Age 44, N=64) 77% returned to work Results of 6 minute walk test are 76% of predicted normal Herridge, M. S., C. M. Tansey, et al. (2011). 13

14 Can We Do Better? There appears to be significant potential for harm arising from the current ICU culture of patient immobility and an often excessive or unnecessary use of sedation. Herridge MS. Mobile, awake and critically ill. CMAJ. Mar ;178(6): We Need The Entire Bundle for Success In adjusted models, those who implemented exercise with sedation interruption and delirium screening were 3.5 [CI ] times more likely to achieve higher levels of exercise in ventilated patients than those who implemented exercise without both sedation interruption and delirium screening. Miller MA, Govindan S, Watson SR, Hyzy RC, Iwashyna TJ: (2015). Klompas M, Anderson D, Trick W, Babcock H, Kerlin MP, Li L, Sinkowitz Cochran R, Ely EW, Jernigan J, Magill S et al: (2015). Let patients speak for themselves, allow them the chance to surprise you Research gives you their narrative rather than our view from the outside 14

15 Elements of a Clinical Practice Guideline Assembling an interdisciplinary task force with a core development group: (GDG) consisting of four PTs who bring a rich blend of strengths in clinical and research scholarship and whose professional affiliations span three APTA Sections. In addition, we will recruit approximately additional interprofessional members (from critical care medicine, nursing, respiratory therapy, and physical therapy) who will be referred to as the content experts (CEs), resulting in an ICU CPG work group of individuals. The core GDG will be responsible for conducting a systematic review of the literature regarding physical therapy in the ICU. Elements of a Clinical Practice Guideline Use of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) method for evaluating the quality of the literature and impact of the interventions A professional librarian to conduct literature searches, a methodologist Maintaining a single electronic data base and providing transparency through out the process Development of clinical questions using the population, intervention, comparison, and outcome (PICO) format Barr J, Kishman CP, Jr., Jaeschke R: The methodological approach used to develop the 2013 Pain, Agitation, and Delirium Clinical Practice Guidelines for adult ICU patients. Crit Care Med 2013, 41(9 Suppl 1):S1 15. Institute of Medicine Standards for Developing CPGs Predetermined criteria for achieving group consensus Equal voice of each task force member Establish transparency Disclosure and management of Conflicts of Interest Explain reasoning of recommendations External review Updating 15

16 APTA Sponsored Clinical Practice Guideline for PT in the ICU 1. Identify the effectiveness of physical therapist (PT) directed interventions; 2. Develop an intervention schema that will inform PT management of patients during CI and help to reduce unwarranted variation in practice 3. Identify key areas of future research. Need for CPG for PT in the ICU Improve PT management of patients with CI and reduce variation in practice; Reduce disability among patients with CI by preventing or minimizing the negative sequelae associated with their condition; Inform intervention strategies for this population Provide guidance for future effectiveness studies. While other systematic reviews and CPGs have been written (or are currently in development) regarding mobility and rehabilitation in the ICU,this will be the first document to specifically address the provision of PT services. Society of Critical Care Medicine Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium (PAD) Guidelines Barr J, et al., Critical Care Medicine 2013 Interpretation of PAD Guidelines Quality of evidence: statements and recommendations High (A) Moderate (B) Low/Very Low (C) Strength of recommendations: recommendations only Either strong (1), weak (2), or none (0) Either in favor of an intervention (+) or against an intervention ( ) 16

17 Society of Critical Care Medicine (SCCM) ICU Liberation Campaign Implementation of PAD Guidelines: Multi professional approach Utilize valid and reliable assessment tools Decrease sedation Prevent complications Barr J, Fraser GL, Puntillo K, Ely EW, Gelinas C, Dasta JF, Davidson JE, Devlin JW, Kress JP, Joffe AM et al: (2013). KEY REFERENCES: Laying the Foundation for E of ABCDEF Bundle Early progressive mobility interventions work Thomsen G. Crit Care Med. 2008;36: Schweickert W. Lancet. 2009;373: Pohlman M. Crit Care Med. 2010;38: Needham D. Arch Phys Med Rehabil. 2010;91: Morris P. Am J Med Sci. 2011;341: Hopkins R. Phys Ther. 2012;92: Lord R. Crit Care Med. 2013;41: Kayambu G. Crit Care Med. 2013;41: Kayambu G. Intensive Care Med. 2015;41: Miller M. Ann Am Thorac Soc. epub May References for Presentation Pires Neto RC, Lima NP, Cardim GM, Park M, Denehy L: Early mobilization practice in a single Brazilian intensive care unit. J Crit Care Ohtake PJ, Strasser DC, Needham DM: Translating research into clinical practice: the role of quality improvement in providing rehabilitation for people with critical illness. Physical therapy 2013, 93(2): Balas MC, Burke WJ, Gannon D, Cohen MZ, Colburn L, Bevil C, Franz D, Olsen KM, Ely EW, Vasilevskis EE: Implementing the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle into everyday care: opportunities, challenges, and lessons learned for implementing the ICU Pain, Agitation, and Delirium Guidelines. Crit Care Med 2013, 41(9 Suppl 1):S Lord RK, Mayhew CR, Korupolu R, Mantheiy EC, Friedman MA, Palmer JB, Needham DM: ICU early physical rehabilitation programs: financial modeling of cost savings. Crit Care Med 2013, 41(3): Lipshutz AK, Fee C, Schell H, Campbell L, Taylor J, Sharpe BA, Nguyen J, Gropper MA: Strategies for success: A PDSA analysis of three QI initiatives in critical care. Joint Commission journal on quality and patient safety / Joint Commission Resources 2008, 34(8): Schweickert WD, Pohlman MC, Pohlman AS, Nigos C, Pawlik AJ, Esbrook CL, Spears L, Miller M, Franczyk M, Deprizio D et al: Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 2009, 373(9678): Daniel CR, Alessandra de Matos C, Barbosa de Meneses J, Bucoski SC, Frez AR, Mora CT, Ruaro JA: Mechanical ventilation and mobilization: comparison between genders. Journal of physical therapy science 2015, 27(4):

18 References for Presentation Thomsen GE, Snow GL, Rodriguez L, Hopkins RO: Patients with respiratory failure increase ambulation after transfer to an intensive care unit where early activity is a priority. Crit Care Med 2008, 36(4): Nydahl P, Ruhl AP, Bartoszek G, Dubb R, Filipovic S, Flohr HJ, Kaltwasser A, Mende H, Rothaug O, Schuchhardt D et al: Early mobilization of mechanically ventilated patients: a 1 day point prevalence study in Germany*. Crit Care Med 2014, 42(5): Jolley SE, Dale CR, Hough CL: Hospital level factors associated with report of physical activity in patients on mechanical ventilation across Washington State. Annals of the American Thoracic Society 2015, 12(2): Pawlik AJ, Kress JP: Issues affecting the delivery of physical therapy services for individuals with critical illness. Physical therapy 2013, 93(2): Holdsworth C, Haines KJ, Francis JJ, Marshall A, O'Connor D, Skinner EH: Mobilization of ventilated patients in the intensive care unit: An elicitation study using the theory of planned behavior. J Crit Care 2015, 30(6): Bakhru RN, Wiebe DJ, McWilliams DJ, Spuhler VJ, Schweickert WD: An Environmental Scan for Early Mobilization Practices in U.S. ICUs. Crit Care Med 2015, 43(11): Damluji A, Zanni JM, Mantheiy E, Colantuoni E, Kho ME, Needham DM: Safety and feasibility of femoral catheters during physical rehabilitation in the intensive care unit. J Crit Care 2013, 28(4):535.e References for Presentation Herridge, M. S., C. M. Tansey, et al. (2011). "Functional disability 5 years after acute respiratory distress syndrome." N Engl J Med 364(14): Miller MA, Govindan S, Watson SR, Hyzy RC, Iwashyna TJ: ABCDE, but in That Order? A Cross Sectional Survey of Michigan ICU Sedation, Delirium and Early Mobility Practices. Annals of the American Thoracic Society Miller MA, Govindan S, Watson SR, Hyzy RC, Iwashyna TJ: ABCDE, but in That Order? A Cross Sectional Survey of Michigan ICU Sedation, Delirium and Early Mobility Practices. Annals of the American Thoracic Society Barr J, Kishman CP, Jr., Jaeschke R: The methodological approach used to develop the 2013 Pain, Agitation, and Delirium Clinical Practice Guidelines for adult ICU patients. Crit Care Med 2013, 41(9 Suppl 1):S1 15. Barr J, Fraser GL, Puntillo K, Ely EW, Gelinas C, Dasta JF, Davidson JE, Devlin JW, Kress JP, Joffe AM et al: Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med 2013, 41(1):