Sedation management for the adult mechanically ventilated patient
From length of stay (LOS) reports, and as recognised by nurse and physician experts, sedation management was problematic for the mechanically ventilated medical intensive care unit (MICU) patient. The growing body of knowledge about sedation management has not been consistently applied in practice, leading to inadequate or oversedation of mechanically ventilated patients, thus prolonging ventilator hours and MICU and hospital LOS and increasing cost.
The purpose of the evidence-based, sedation management project was to implement evidence-based sedation management practices for the mechanically ventilated critically ill adult patient and thereby, improve patient outcomes related to sedation. Anticipated improvements in patient outcomes were (a) decrease in the duration of mechanical ventilation, (b) decrease in MICU and hospital LOS, and (c) decrease in cost per case. Objectives to achieve these goals include (1) increasing nurses’ knowledge regarding evidence-based sedation management practices; (2) increasing documentation of the level of sedation, interventions, and reassessment; and (3) developing and implementing an evidence-based sedation management practice protocol inclusive of analgesic and sedative titration using level of sedation and daily interruption of sedatives for a “wake-up” test.
SYNTHESIS OF EVIDENCE
Evidence was obtained through advanced search strategies using Medline and CINAHL. MeSH search terms used in the Ovid database searches included conscious sedation, mechanical ventilation, agitation, critical care, critical nursing, drug monitoring, sedatives, narcotics, and Propofol. Two members of the project team reviewed all relevant citations for practice implications. The literature search identified several clinical practice guidelines or protocols for administration of intravenous sedation for mechanically ventilated adults.
The research also corroborates that long term mechanical ventilation is associated with significant patient risks, such as ventilator associated pneumonias, nosocomial infections, debilitation, and the need for a tracheostomy. Research suggests that lack of a sedation protocol in an ICU is associated with prolonged sedation, longer ventilation times, longer hospital stays, and higher costs. Evidence suggests that the use of a protocol directed sedation policy decreases the duration of mechanical ventilation for patients with acute respiratory failure compared with non-protocol directed care. Evidence also indicates that the total duration of continuous intravenous sedation is associated with decreased ventilator hours. The success of a sedation management protocol seems to be achieved in part by allowing rapid clinical decision making at the patient’s bedside. Clinical practice guidelines in conjunction with research reports provided the research based evidence to guide practice and achieve the desired clinical outcomes for sedation management in the mechanically ventilated (> 96 h) patient.
CHANGE IN PRACTICE
Changes included development and implementation of an agitation and sedation scale; implementation of a sedation protocol for the adult mechanically ventilated patient, including use of combination drug therapy; and the addition of a daily wake-up assessment. Changes in practice were done through a team approach led by an advanced practice and staff nurse partnership and supported through a department of nursing internship programme.
Successful evidence-based clinical practice change involves organisational and individual commitment. A sedation management team was formed and consisted of an ICU staff nurse, advance practice nurse, nurse manager, assistant nurse manager, pulmonary fellow, staff physician, and pharmacist. Research evidence, clinical practice guidelines, and protocols were synthesised and shared with physicians and pharmacists to gain their support and feedback. A core group of nurse change champions were provided advanced consultation and education, and pre-printed order sheets were developed to facilitate infusion of the practice change. ICU nurses were educated through posters, verbal inservices, and formal didactic and consultative sessions. Pre-implementation and post-implementation data were analysed, and audit feedback was used to share results with staff and for re-infusion of the protocol after 6 months.
METHOD OF EVALUATION
Baseline and post-implementation data were obtained from chart audits, a nursing knowledge survey (60% return rate), and our Clinical Outcomes and Resource Management department. Descriptive statistics and process control measures were used to analyse the data. Process and outcome indicators were used to evaluate the change in practice. Process indicators included an increased knowledge level of nurses regarding evidence-based sedation management practices (knowledge survey); use of a standard tool to document level of sedation, number of times sedation level was documented per each 24 hours of mechanical ventilation, and routine use of an agitation scale; and daily assessment of the patient without sedation (chart audits). Outcome indicators included length of time on the mechanical ventilator, MICU and hospital LOS of the mechanically ventilated patients (ICD-9 procedure code 9672), and mean hospital cost.
The knowledge survey indicated that staff was knowledgeable about pharmacological aspects of benzodiazepine use, but they were less satisfied with sedation management in general. Data from chart audits indicated that there were no structured mechanisms or tools being used to document the level of sedation (ie, there were 175 different terms being used to document sedation level). After implementation of the agitation and sedation scale and the sedation management protocol, the number of times sedation level was documented increased from 3.5 to 10.9 times per 24 hour period.
After implementation of the sedation management protocol, the average ventilator days decreased from 10.3 to 8.1 (2.2 days). LOS for patients ventilated longer than 96 hours in the ICU decreased from 11.4 to 9.1 (2.3 days). The average hospital cost decreased from approximately $42 000 to $26 000, a savings of around $16 000 per patient or a total institutional cost savings of $352 000 over a 5 month period.
Change involves both organisational and individual commitment and team effort. This was largely a nurse driven practice change necessitating garnering support and enthusiasm from both physicians and pharmacy. It was necessary to find a key physician to partner with us. Infusion into practice is an ongoing effort in which continued support from nurses, physicians, and pharmacy is difficult. There is an ongoing need to enhance sedation management support and resources, measure the effectiveness of the sedation management protocol, and develop additional evidence-based practice improvements. The project is ongoing in 1 unit and will expand to other adult ICUs to enhance multidisciplinary collaboration and improve patient outcomes.