Improving Sedation in the ICU by Adhering to National Guidelines and Recommendations

Over five million individuals are admitted to a critical care unit in the United States each year. The number one diagnosis for admission is respiratory failure. Something as simple as decreasing the amount of medication a patient receives can improve outcomes for this large and vulnerable patient population. This prospective quality improvement project aims to develop a simplistic sedation management order-set for patients requiring mechanical ventilation at a local community hospital intensive care unit. Surveys have shown that very few ICU providers use a sedation protocol and even fewer perform interruption of sedation on a daily basis. Literature dating back to 2002 has shown the benefit of a daily interruption of sedation therapy including a decrease in mortality, reduction of delirium, fewer days requiring mechanical ventilation, shorter length of hospital stay, and decrease cost of health care. The last five years of evidence has shown that targeting a level of light sedation is as effective as daily sedation interruption. The project met its intended purpose through five objectives. An order-set was adapted from national guidelines and recommended care bundles provided by the Society of Critical Care Medicine and the ICU Delirium and Cognition Study Group. The nursing staff were educated during a monthly staff meeting and newsletter on proper sedation use and assessment. Nursing education was evaluated with a post-test. Providers in the ICU implemented the order-set. Compliance with the order-set was assessed through documentation of the Riker Sedation-Agitation Scale (SAS) in the mechanically ventilated patients from the beginning of order-set implementation to the end of the one-month study period. Throughout implementation of the order-set nursing staff was updated on compliance and subsequent discussion included benefits and concerns with the order-set. A copy of the order-set and the data collected was submitted to other Critical Care Directors in the hospital's corporate region for dissemination to other Utah facilities. Data analysis showed an average SAS score of 3.51, which reflects the target score recommended by national guidelines. Ten patients were mechanically ventilated for a total of 64 ventilator days. Order-set use by providers encompassed 100% of ventilated patient over the course of the study. The order-set received praise from multiple Intensivists who were pleased with the simplicity of it composition and acceptance by the nursing staff. Nursing compliance with SAS charting was 85% with a total of 308 SAS scores recorded. Recorded high dose of continuous propofol was lower in the study period (40 mcg/kg/min) compared to the pre-study period (71.1 mcg/kg/min). The order-set was approved by hospital administrators and submitted to four other Critical Care Directors in the Utah region for potential adoption in other corporate facilities. The Critical Care Committee at the local hospital created a sub-committee that will continue monitoring the use and compliance of the order-set. Sedation is most effective when used properly instead of excessively. Reducing its use has the potential to improve the short-term and long-term outcomes of patients who so desperately need every advantage in optimizing care. Decreasing sedation is a simple, safe and effective way to save an individual's life and preserve their quality of life.