Improved Adherence to Sedation and Weaning Protocols in Ventilated Patients: A Quality Improvement Project

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Webb, Melanie
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Background: Adverse outcomes related to mechanical ventilation continue to prevail as a local, national, and global health problem. Ventilator associated events carry significant morbidity and mortality. The prevention and mitigation of adverse events is guided by clinical guidelines that address management of sedation and analgesia, mechanical ventilation liberation, delirium management, and early mobility in the “ABCDE” care bundle. Mounting evidence suggests that the type and depth of sedation significantly contributes to the incidence of delirium and intensive care-acquired weakness that has long-term ramifications for survivors of critical illness. Despite evidence-driven guidelines that recommend protocolized management of ventilated patients, wide variability persists between individual caregivers and disciplines in adhering to these recommendations. Closing the gap between evidence and practice is contingent upon a framework that explores and elucidates the complexities that impede adherence, thereby ensuring implementation sustainability.|Methods: A retrospective, preintervention collection of patient data that was analyzed to identify usual patterns of management of sedation/analgesia and weaning practices in mechanically ventilated patients. From this data, an educational module was developed that focused on unit-specific practices that could be targeted to improve adherence to care bundle. This module was taught to the Critical Care Staff. A postintervention review of identical data was collected to evaluate improvement of targeted measures.|Results: The two groups were similarly sized, but with less average hours of ventilation in the post-intervention group. Routine pain assessments on day shift showed significant improvement (p=0.0007), as did the documentation of SBT, which was achieved in 95% of patients. The documentation of the SAT improved significantly (p=0.0019), although still only accomplished in 30% of patients. The frequency of analgesic given without pain assessment on night shift was improved, but not to a statistically significant level. Rates of over sedation (RASS -3 to -5) were documented with similar frequency in both groups (9% days, 12% nights). Oversedation was not proven out. Continued barrier identification and mitigation will be necessitated to improve patient outcomes in this complex setting
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