Five meetings were necessary to elaborate the quality study design. The first nursing care procedure in the morning was chosen to be studied because it accounts in our ICU for all targets the care which requires the longest duration of turning, including the largest number of moves and nursing care procedures in the day (bathing, massage of back and pressure points, sheet changing, repositioning, frequent change of dressings and placement of stockings and foot splints). Also, the work group had the impression that there was a strong contrast between the end and beginning of the day regarding pain, agitation and the number of alarms ringing from monitoring systems early in the morning. Contrary to pain at rest, pain during procedures was rarely reported in medical charts.

We made the hypothesis that managing procedural pain during the first turning of the day would be the most challenging in our ICU. Figure Figure11 represents the study design that included four one-month studied phases separated by interphase periods of four to six months, according to the Plan-Do-Check-Adjust method [20-22]. Total length of the study was 20 months. The present quality improvement process was the third quality process performed in the ICU regarding the management of sedation and analgesia. The first quality improvement process, aimed at implementing a systematic assessment of pain and agitation in the ICU using validated tools, was initiated in 2002 and evaluated in 2003 [1]. The second project (2006 to 2007) was aimed at evaluating nurse interventions regarding a sedation-analgesia algorithm and at comparing them to a North American ICU [18].

Figure 1Study-design and quality method. This figure represents the quality-improvement process of pain and serious adverse events while moving ICU patients for turning and nursing care procedures. This 20-month process following the P-D-C-A steps was evaluated …”Do- step -A”: studied phase-1 (February 2010)Every first turning of the day, between 6 and 8 AM was evaluated (see below, evaluated parameters).During this phase, a de-identified questionnaire was given to every RN and nurse assistant in order to assess their knowledge of written guidelines regarding sedation-analgesia in the ICU and their difficulties in managing sedation-analgesia routinely.”Do-step B”: first inter-study phase (March to August 2010)Based on Phase 1 and questionnaire results, educational Carfilzomib interventions were planned and educational posters were constructed and posted. Educational intervention was provided for all the nursing and medical staff by members of the work group during scheduled courses intended for 5 to 10 staff members at a time.