*Dosing information in Table 1 has been changed to correct an editorial error found in the print edition of Critical Connections. Dosing amounts for fentanyl and propofol should be reflected in micrograms as seen below. Critical Connections regrets the error.
Click here to download a revised PDF.
Developing and Implementing a Successful ICU Sedation Guideline:
One Hospital’s Strategy
Gail Gesin, PharmD*
Orlando Regional Medical Center
Orlando, Florida, USA
John W. Devlin, PharmD, FCCM*
Northeastern University
School of Pharmacy
Boston, Massachusetts, USA
The 2002 American College of Critical Care Medicine/Society of Critical Care Medicine (ACCM/SCCM) sedation guidelines advocate the use of a guideline, protocol or algorithm to guide sedation therapy in the intensive care unit (ICU) [Grade B recommendation] based on studies demonstrating that their use shortens the duration of mechanical ventilation, decreases length of ICU stay and lowers sedation drug costs.1-4 Despite these proven benefits, survey data suggest that sedation protocols are being used to manage patients in less than half of ICUs.5 In addition to the various challenges and complexities associated with the development and implementation of protocols in clinical practice, several barriers are specific to the use of sedation protocols. These include physicians not using them when ordering sedation, a perceived lack of applicability to some patient populations, a lack of nursing support and a fear of oversedation.6 In this article, we will describe the development, implementation and subsequent modification of a sedation guideline by a multiprofessional task group of clinicians from the surgical critical care team at Orlando Regional Medical Center (ORMC), a 581-bed community teaching hospital and level one trauma center with 64 ICU beds.
Selection and Implementation of a Sedation Scoring System Before developing our guideline, we identified the need to implement a sedation scoring system validated for use in adult, critically ill patients. We selected the Riker Sedation-Agitation Scale (SAS) over other available scales because of its perceived ease of use.7 We agreed that SAS assessments should be completed and documented at least hourly. To accommodate this practice, the ICU flow sheet was redesigned to add a column next to the existing field for recording pain assessments. Additionally, a detailed description of the SAS was inserted to facilitate scoring. We chose not to incorporate a delirium assessment tool (e.g., Confusion Assessment Method for the ICU) in the initial guideline, believing it was best to introduce practice changes to the multiprofessional team in a sequential fashion.
Selection of Medications and Dosing Strategies
Using the ACCM/SCCM sedation guidelines as a starting point, we identified a number of drug- and administration-related concerns that would require individualization to our institution. Drug selection was based on our patient population (e.g., general surgical, trauma and neurotrauma), anticipated duration of sedation therapy, clinician experience, formulary status and cost. We selected benzodiazepines as first-line agents and reserved propofol for patients with neurotrauma or refractory agitation. The guidelines advocated maintaining patients at an SAS score of 3 to 4 for titration of sedation therapy. They recommended that benzodiazepines be administered intermittently rather than by continuous infusion, given the risk for accumulation and prolonged sedation with infusions.8 In an effort to minimize the complexity of the new guideline, we did not include a strategy for daily interruption; however, this was introduced later for those patients receiving continuous sedation therapy.
Presentation of Information
The task force had to decide whether to develop a mandatory protocol, general guidelines or a specific algorithm. After reviewing examples of sedation protocols and algorithms from other institutions, we determined that a guideline would meet our needs best. The hospital’s ICU clinicians were familiar with this format, and we recognized that the diversity of our patient population would make it difficult to establish one routine, protocolized approach to sedative therapy. In addition, we felt that the staff’s practice of frequently modifying sedation therapy (e.g., drug, dose and route of administration) would result in an overly complex protocol. Our guideline included a brief overview of ICU sedation, a literature review highlighting key articles, and a summary of graded recommendations.
We intended the document to be educational in nature and to provide a concise summary of recommended actions to facilitate decision making by the healthcare team. We added a disclaimer statement indicating that the recommendations were intended as guidelines only and that deviation might be necessary in some circumstances. The document was placed on the surgical critical care team’s Web site for easy access.
Educational Support
Educational strategies to introduce new practices, such as a sedation guideline in the ICU setting, should be multifaceted.9 Our unit-based nurse educators used memos and informal discussions to conduct nursing education on the new scoring system and guideline. Other members of the healthcare team were educated during informal discussions on rounds. Multiple educational approaches specific to the topic of sedation have been described.10 The sedation protocol (or at least the highlights of it) should be accessible at the bedside, on pocket cards and on Web sites. Incorporating information from algorithms or protocols into physician order sets and/or computerized physician order entry also is an effective strategy to ensure clinicians are educated continuously.
Process Evaluation
Following the development and implementation of a new process, it is important to establish a method for multiprofessional team members to provide feedback. Although we did not have a formalized evaluation process in place, we were asked by a neurosurgeon to re-evaluate our use of benzodiazepines in the neurotrauma population. During monthly meetings, members of the healthcare team provided feedback that ultimately led to the development of a separate neurotrauma sedation protocol (see Table 1) and adjunctive order set for propofol infusions. The department of neurosurgery and the critical care and pharmacotherapy committees approved both documents. While the ICU leadership team was aware of these process changes, we found that formalized education regarding the new protocol and order set was delivered inconsistently to different members of the ICU team. Now, there is a need to redouble our education efforts.
Conclusion
Numerous steps must be considered when developing and implementing a sedation guideline or protocol. Any institutional sedation guideline process should be led by a multiprofessional team whose members should first evaluate current ICU sedation practices within the institution. An individualized plan then must be developed to fit the needs of the particular ICU(s). If resources are limited, one should consider focusing on sedation strategies most likely to improve patient outcomes, such as the implementation of a validated scoring system.
*Author has no disclosures to report.
Table 1: Protocol for Acute Sedation and Pain Management of Neurotrauma Patients (Age > 16)
Protocol is for 48 hours following admission only.
CRITERIA
• Age >16 years
• Initial Glasgow Coma Score <8 and suspected/documented intracranial bleed
ACTIONS
• For patients NOT mechanically ventilated
o Sedative
- Midazolam 2mg IV x 1 dose for agitation
o Analgesic
- Fentanyl 12.5mcg IV x 1 dose for pain
o Subsequent orders for anxiolytic and/or analgesic therapy to be determined based on patient response
• For patients mechanically ventilated
o Sedative
- Initiate propofol 5 mcg/kg/minute and titrate by 10 mcg/kg/minute increments up to 50 mcg/kg/minute to achieve a Sedation-Agitation Scale (SAS) of 2 to 3
1. Propofol Infusion Protocol for Neurotrauma Patients (Age >16) is available on SWIFT
- If propofol doses exceeding 50 mcg/kg/minute are needed to control elevated intracranial pressure, the following precautionary measures are to be initiated/continued:
1. Baseline and daily EKG
2. Baseline triglyceride level
3. Baseline and daily ionized calcium and creatine kinase levels
4. Calcium chloride replacement protocol if central intravenous access is available
o Analgesic
- Fentanyl 25 to 50mcg IV Q1HR PRN PAIN
References
1. Jacobi J, Fraser GL, Coursin DB, et al. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med 2002; 30:119-141.
2. Brattebo G, Hofoss D, Flaaten H, et al. Effect of a scoring system and protocol for sedation on duration of patients’ needs for ventilator support in a surgical intensive care unit. BMJ 2002; 324:1386-1389.
3. Brook AD, Ahrens TS, Schaiff R, et al. Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation. Crit Care Med 1999; 27:2609-2615.
4. Duane TM, Riblet JL, Golay D, et al. Protocol-driven ventilator management in a trauma intensive care unit population. Arch Surg 2002; 137:1223-1227.
5. Mehta S, Burry L, Fischer 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.
6. Devlin JW, Tanios MA, Epstein SK. Current practices, beliefs and attitudes on sedation in the intensive care unit using a large scale national survey. Crit Care Med 2004; 32:A259.
7. Riker RR, Picard JT, Fraser GL. Prospective evaluation of the Sedation-Agitation Scale for adult critically ill patients. Crit Care Med 1999; 27:1325-1329.
8. Kollef MH, Levy NT, Ahrens TS. The use of continuous IV sedation is associated with prolongation of mechanical ventilation. CHEST 1998; 114:541-548.
9. Curtis RJ, Cook DJ, Wall RJ, et al. Intensive care unit quality improvement: A “how-to” guide for the interdisciplinary team. Crit Care Med 2006; 34:211-218.
10. Pun BT, Gordon SM, Peterson JF, et al. Large-scale implementation of sedation and delirium monitoring in the intensive care unit: A report from two medical centers. Crit Care Med 2005; 33:1199-1205.
