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Comfort Scoring Scale for Mechanically Ventilated Pediatric Patients

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on 24 April 2014

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Transcript of Comfort Scoring Scale for Mechanically Ventilated Pediatric Patients

Thank You!
Children are intubated for a variety of underlying reasons, the most common is respiratory failure.

While our pediatric patients are relying on mechanical ventilation to breath, they rely on us to make sure they are not in any pain or discomfort.
The FLACC Pain Scale is highly trusted and well validated to determine a patient's pain.

It is made for patients under the age of 2 months, but has shown to have valid application to most other mechanically ventilated patients.


What do we do with the COMFORT score?
After evaluation by a RN, if the patient scores above 26 the nurse will be prompted to a Midazolam bolus. The dose can be repeated every 10 minutes x 3 doses. If the C-score remains above 26, the physician should be notified.



Morgan Pick
Spring 2014
Children's Hospital at University of Illinois

Comfort Scoring Scale for Mechanically Ventilated Pediatric Patients
Mechanical Ventilation in the PICU
PAIN !
Fentanyl is most commonly used as an analgesic to relieve patient pain while mechanically ventilated.
Evaluating a Patient's Pain
Since FLACC scoring measures pain, we will call this the pain score, p score for short. A p score of less than 4 indicates no pain, a score equal or greater than 4 means the patient is in pain.
How to Read a FLACC Score
With a pain score above 4, a standing order will be acted upon by the nurse. A Fentanyl bolus will be given. If this action is taken 3 consecutive times and the p-score is still 4 or above, the physician needs to be notified.
P-Score = or >4
While we previously addressed pain, comfort, in terms of sedation, is something different. Comfort, by a sedation standpoint, is the level of sedation given to the patients.
Comfort and Sedation
Previously, the COMFORT Scale for Sedation was being utilized. The COMFORT Scale can be used for mechanically ventilated patients of any age.

8 Categories

40 Possible Points

Can take up to 7 minutes to complete.
How do we measure comfort?
Potential Problems:
How sedated does the physician want the patient to be?
Scoring may take longer than desirable for patient/ family/nurse/physician satisfaction.
How can we improve the comfort of our mechanically ventilated pediatric patients?
Implement a shorter, easier to use comfort scale.
Establish sedation levels that are physician driven.
What are the comfort issues associated with mechanically ventilated patients?
no objective measurement
boluses given without documentation
no justification for bolus
no MD order in place

Comfort Scoring Scale
Extensive literature review shows positive patient results when using a comfort scale to determine sedation levels
Will provide a rationale for giving a bolus
Decreases subjectivity
No scale currently in use at Children's Hospital at the University of Illinois at Chicago

Is it pain or discomfort?

Implementing a MD scoring tool for sedation of mechanically ventilated patients.
Where to start?
Why would this help?

What would it look like?
Implement a comfort scoring system that increases patient comfort and safety, matches actual patient sedation with MD goal number for sedation, is easy to use, and correlates well to bolus dosing.
Ultimate Goal

Let's Compare...
COMFORT Scale
State Behavioral Scale
Hartwig Scale
Validated
7 patient characteristics
6 levels of sedation
-3 is the most sedated
The State Behavioral Scale
Positives
Potential Negatives
No suctioning required.
Many levels of sedation and multiple scales involved.
Validated*
5 Patient Characteristics
25 possible points
Score of 8 is the deepest sedation
Uses suctioning as a characteristic
The Hartwig Scale
Positives
Potential Negatives
Uses suctioning as a characteristic
Smaller number of characteristics and points
C
O
M
F
O
R
T
Hartwig
State Behavioral
let's try...
(vs 8 with the COMFORT scale)
(vs 3 with the COMFORT scale)
(vs 8 with the COMFORT scale)
(vs 40 with the COMFORT scale)
Benefits of a Comfort Scale
decreased unplanned extubations
decreased VAP
decreased LOS
decreased time on vent
decreased sedation days
decreased delerium
What did you think?
Do you think this is reasonable?
References

Bear, L. A., & Ward-Smith, P. (2006). Interrater reliability of the COMFORT Scale. Pediatric nursing, 32(5).
Cannon, M. L. (2011). Protocol-driven sedation: Will both the patient and physician be more comfortable?*. Critical care medicine, 39(4), 887-888.
Carvalho, W. B. D., Silva, P. S. L. D., Chiu, S. T. P., Fonseca, M. M. C., & Belli, L. A. (1999). Comparison between the Comfort and Hartwig sedation scales in pediatric patients undergoing mechanical lung ventilation. Sao Paulo Medical Journal, 117(5), 192-196.
Curley, M. A., Harris, S. K., Fraser, K. A., Johnson, R. A., & Arnold, J. H. (2006). State Behavioral Scale (SBS) A sedation assessment instrument for infants and young children supported on mechanical ventilation. Pediatric critical care medicine: a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies, 7(2), 107.
De Jonghe, B., Cook, D., Appere-De-Vecchi, C., Guyatt, G., Meade, M., & Outin, H. (2000). Using and understanding sedation scoring systems: a systematic review. Intensive care medicine, 26(3), 275-285.
Deeter, K. H., King, M. A., Ridling, D., Irby, G. L., Lynn, A. M., & Zimmerman, J. J. (2011). Successful implementation of a pediatric sedation protocol for mechanically ventilated patients*. Critical care medicine, 39(4), 683-688.
Hartwig, S., Roth, B., & Theisohn, M. (1991). Clinical experience with continuous intravenous sedation using midazolam and fentanyl in the paediatric intensive care unit. European journal of pediatrics, 150(11), 784-788.
Hünseler, C., Merkt, V., Gerloff, M., Eifinger, F., Kribs, A., & Roth, B. (2011). Assessing pain in ventilated newborns and infants: validation of the Hartwig score. European journal of pediatrics, 170(7), 837-843.
Ista, E., van Dijk, M., Tibboel, D., & de Hoog, M. (2005). Assessment of sedation levels in pediatric intensive care patients can be improved by using the COMFORT “behavior” scale*. Pediatric Critical Care Medicine, 6(1), 58-63.
Johansson, M. and Kokinsky, E. (2009), The COMFORT behavioural scale and the modified FLACC scale in paediatric intensive care. Nursing in Critical Care, 14: 122–130. doi: 10.1111/j.1478-5153.2009.00323.x
Miner, J. R. (2012). The Future of Pediatric Sedation. In Pediatric Sedation Outside of the Operating Room (pp. 477-490). Springer New York.
Tobias, J. D. (2005). Sedation and analgesia in the pediatric intensive care unit. Pediatric annals, 34(8), 636-645.
Popernack, M. L., Thomas, N. J., & Lucking, S. E. (2004). Decreasing unplanned extubations: utilization of the Penn State Children’s Hospital sedation algorithm. Pediatric Critical Care Medicine, 5(1), 58-62.
Vet, N. J., Ista, E., de Wildt, S. N., van Dijk, M., Tibboel, D., & de Hoog, M. (2013). Optimal sedation in pediatric intensive care patients: a systematic review. Intensive care medicine, 39(9), 1524-1534.
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