Daily Pharmacist Supervision of Sedation Guideline Adherence Gets Patients off Mechanical Ventilation Faster
Abstract & Commentary
By Leslie A. Hoffman, PhD, RN, Department of Acute/Tertiary Care School of Nursing, University of Pittsburgh, is Associate Editor for Critical Care Alert.
Dr. Hoffman reports no financial relationship to this field of study.
Synopsis: Institution of a daily pharmacist-enforced intervention designed to improve adherence to sedation guidelines decreased the duration of mechanical ventilation and ICU stay.
Source: Marshall, J. et al. Crit Care Med. 2008;36: 427-433.
Although protocol-driven sedation and analgesia management has been shown to improve patient outcomes, adherence to these guidelines is often poor. The authors of this study hypothesized that consistent pharmacist supervision would promote adherence to existing sedation guidelines, and therefore improve clinical outcomes. The study enrolled 156 mechanically ventilated patients on continuous sedation admitted to two medical ICUs in a university medical center. The control group (n=78) consisted of patients managed without pharmacist intervention in the 3 months prior to the study. In the intervention group (n=78), patients underwent daily assessment by a pharmacist who suggested changes, if indicated, based on the institution's previously approved sedation guidelines. These recommendations, conveyed verbally to the bedside nurse and physicians, included suggestions regarding medication choice, titrating to the sedation goal and identifying pain and delirium. The recommendations also included suggested changes in sedation based on organ function and laboratory tests, eg, serum triglycerides, serum osmolarity. The pharmacists who carried out the intervention were pharmacy residents or residency trained pharmacists.
With the protocol, duration of mechanical ventilation was reduced from 338 ± 348 hrs (14 days) to 178 ± 178 hrs (7.8 days) (p <.001). There was also a significant reduction in the duration of ICU stay (p =.001) and hospital stay (p =.001). No significant differences were seen for hospital mortality (p=0.8299), need for tracheostomy (p=.0788), self-extubation (p=.2096), reintubation (p=7972), or the percentage of patients placed on physical restraints (p=.8697). There were a total of 210 pharmacist interventions, with 91% of the interventions accepted.
Commentary
Although shown to be effective, sedation protocols are inconsistently applied. In a recent Canadian survey, only 29% of critical care practitioners reported using a sedation protocol or guideline.1 The intervention tested in this study has many attractive features. Many ICUs include pharmacists on the rounding team. It would be a simple step to add responsibility for monitoring adherence to the selected sedation protocol to their responsibilities.
In the present study, pharmacy residents and residency trained pharmacists were the "interventionists," suggesting easy integration into training programs. The guidelines used by the Medical Center in which the study took place were developed in a manner designed to promote adherence. Following publication of the Society of Critical Care Guidelines for the use of sedation and analgesics,2 the Center updated their sedation guidelines using a multidisciplinary team. Approval was followed by an educational initiative that included lectures, provision of the guidelines in written form, and yearly nursing competency reviews. Despite this effort, a 1-year audit demonstrated poor compliance and promoted the present study.
An important consideration relates to the sedation guideline used in this study. The first step was to set a sedation goal using the Sedation Agitation Score (SAS). Sedation was titrated to this goal by first identifying and treating the etiology of agitation (pain, anxiety, delirium) and then actively "down-titrating" sedative administration by 25% every 4 hours in the case of over-sedation. Daily sedation interruption was not used. The most common pharmacist intervention was to add an analgesic to improve pain management and/or haloperidol to treat delirium. Such actions targeted the etiology of agitation, allowing more appropriate treatment, in contrast to the inappropriate, but commonly chosen, practice of increasing the sedation dose. In the authors' opinion, such actions were a primary cause of the positive outcomes. A second important step was the addition of outpatient psychiatric medications, which had the benefit of preventing withdrawal syndromes. Finally, the intervention was designed to actively involve nurses and physicians by introducing recommendations at the bedside, accompanied by a discussion of the rationale. The approach tested in this study has the potential to promote adherence to a practice with known benefits by expanding the contributions of an important member of the clinical care team.
References
- Jacobi J, et al. Clinical practice guidelines for the sustained use of sedative and analgesics in the critically ill adult, Crit Care Med. 2002;30:119-141.
- Mehta S, et al. Canadian survey of the use of sedatives, analgesics, and neuromuscular blocking agents in critically ill patients. Crit Care Med. 2006;34:374-380.
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