Who's handling the sedation? New evidence shows nurses should
Savings increase, LOS decreases when nurses decide
In the 1970s, the Ramones wrote the song "I Wanna Be Sedated." In the 1990s, ICU researchers say too many ICU patients are sedated and for too long.
A study conducted by researchers at Washington University School of Medicine in St. Louis found that by letting nurses have more control over levels of sedation, patients spent on average one day less in the ICU. The randomized controlled trial, led by Marin Kollef, MD, a physician at Barnes-Jewish Hospital, which is affiliated with the medical school, and associate professor of medicine at Washington University, involved about 350 patients. Data collection for the study titled "The Effects of Sedation Protocol on ICU Length of Stay" was completed in late August.
"We found the number of days in the ICU was cut from 7.3 to 5.9, a statistically relevant number," says Thomas Ahrens, MD, with the department of nursing at Washington. "The total hospital stay was about four days less. We probably saved the hospital $200,000 or more."
Preliminary results show that nurses are in a better position than physicians to make the decision of when to wean patients from sedation, Ahrens says. Results of the study will be presented at the annual meeting of the American Thoracic Society in San Diego April 23-28, according to Kollef.
The trial came on the heels of a different study on IV sedation by the same research team, the results of which were published in the August issue of Chest, the journal of the American College of Chest Physicians.
That study, "The Use of Continuous IV Sedation Is Associated with Prolongation of Mechanical Ventilation," found a connection between the administration of continuous IV sedation and the prolonged use of mechanical ventilators.
Of 242 patients, about 38% were given continuous IV sedation; approximately 62% were administered bolus (pill) sedation or no sedation. The study found the length of time spent on mechanical ventilation was "significantly longer for patients receiving continuous IV sedation" vs. those not receiving it."
Patients on continuous IV sedation spent about 185 hours on mechanical ventilation compared to 55 hours for those on other or no sedation programs. Patients who received continuous IV sedation remained in the ICU for an average of 13.5 days vs. 4.8 days for patients not given continuous IV sedation while on a ventilator.
Contradiction of earlier study
Interestingly, the more recent study which looked at an ICU nursing protocol for sedation administration appeared to somewhat contradict the earlier IV sedation study published in Chest, says Donna Prentice, RN, MSN, a critical care clinical nurse specialist, also with Washington University, who worked on both studies.
"The duration of time spent on mechanical ventilation in the second study was less on protocol vs. on non-protocol, but it did not reach statistical significance," she says. "However, the trend [toward less IV sedation meaning less time on mechanical ventilation] is still there."
Thomas Petty, MD, professor of medicine at the University of Colorado Health Sciences Center in Boulder, expressed his concerns about the use of sedation in ICU wards in the August issue of Chest.
In an editorial, Petty states, "I am troubled when I make rounds in critical care units today because of the grotesque and inhuman scenarios that I so frequently encounter. What I see these days are paralyzed, sedated patients, lying without motion, appearing to be dead, except for the monitors that tell me otherwise. Why this syndrome of sedation and paralysis has emerged baffles me because this was not the case in the past. We rarely paralyzed patients unless they were convulsing or totally out of control.
"I am afraid that the conspiracy between the requirements of high acuity care and available pharmacological therapy has led to the present situation."
Kollef agrees. "Yes, I think greater availability of drugs is the reason patients are sedated more."
"Until the '70s we just didn't have that many drugs to sedate patients with other than diaze-pam and chlordiazepoxide," adds Ahrens, who has 20 years' experience in the ICU. "We used to hardly ever put patients on fentanyl or morphine. Increases began in the '80s and continued in the '90s."
Sedatives primarily used in the study on the use of continuous IV sedation were benzodiazepines and narcotics. Propofol was not used much "because it's rather expensive. Also it can cause lipid buildup and liver failure," he says.
Kollef says he believes ICUs are behind birthing units and cancer wards in developing creative methods for making patient stays comfortable. "We don't do enough with music therapy or other therapies to create a soothing environment."
Hospitals are not staffed as well as they once were, Ahrens adds. "When staffing is poor, we have a tendency to keep patients more sedated because they're easier to manage. We see staffing ratios now we would never have seen before. In our unit today, we have several nurses with three patients each. "If you have someone on mechanical ventilation and you don't want them to extubate themselves, one thing you can do is be sure they're well-sedated," he says.
Ahrens says while he has not seen a rise over the past 20 years in complications resulting from mechanical ventilators, how and when the ventilators are used should be carefully controlled. Risks to patients who are put on mechanical ventilators include ventilator-associated pneumonia and airway complications such as tracheal stenosis and ulceration.
Whether a patient needs sedation and how much he or she should have must be determined case by case, Kollef says. He stressed physicians should not automatically assume because a patient needs a mechanical ventilator, he or she must have continuous IV sedation.
"Sometimes a patient needs to be sedated, sometimes he can remain awake while he's on a ventilator," Kollef explains.
Physicians today are not at a lack for sedative agents, he adds, but these need to be used "in an optimal manner."
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