POPULATION OF INTEREST

All injured patients

INTENT (EXPECTED OUTCOMES)

- Patients in the population of interest have a documented pain assessment at every role of care.
- Patients in the population of interest in the intensive care unit are screened for delirium daily.
- Intubated patients will not experience an inadvertent or unplanned extubation.

PERFORMANCE ADHERENCE METRICS

- Number and percentage of patients in the population of interest who have a documented pain assessment at each role of care.
- Number and percentage of patients in the population of interest in the intensive care unit with documented delirium screen daily.
- Number and percentage of intubated patients who experience an inadvertent or unplanned extubation.

DATA SOURCE

- Patient Record
- Department of Defense Trauma Registry (DoDTR)

SYSTEM REPORTING & FREQUENCY

The above constitutes the minimum criteria for PI monitoring of this CPG. System reporting will be performed annually; additional PI monitoring and system reporting may be performed as needed.

The system review and data analysis will be performed by the JTS Chief and the JTS PI Branch.

RESPONSIBILITIES

All healthcare providers will:

- Become familiar with the guidelines for the management of pain, anxiety, and delirium in critically injured patients.
- Appropriately manage patients with pain, anxiety, and delirium.
- Provide feedback on these guidelines and suggestions for changes to the CPG to the JTS Chief, Pain Director and Intensivist at each Level III facility will:
  - Implement care that is consistent with the intent of this CPG.
  - Monitor adherence with the CPG.