Elsevier

Collegian

Volume 23, Issue 3, September 2016, Pages 275-284
Collegian

Trajectory of sedation assessment and sedative use in intubated and ventilated patients in intensive care: A clinical audit

https://doi.org/10.1016/j.colegn.2015.06.003Get rights and content

Summary

Background

Sedation is crucial for the recovery of patients in intensive care units (ICUs). Maintaining comfort and safety promotes optimal care for critically ill patients.

Purpose

To examine sedation assessment and management undertaken by health professionals for mechanically ventilated patients in one Australian ICU.

Methods

A retrospective clinical audit was undertaken of medical records of all eligible, mechanically ventilated patients admitted to an ICU of an Australian metropolitan, teaching hospital over a 12-month period. A Sedation Audit Tool was used to collect data from the day of intubation to 5 days after intubation.

Findings

Data were extracted from medical records of 150 patients. The Riker Sedation-Agitation Scale (SAS) was the scoring system used. Patients were unarousable or very sedated between 57% and 81% at some point during the study period, while between 5% and 11% were agitated, very agitated or extremely agitated across this time. Patients’ sedation scores were not documented in between 3.3% and 23.3% of patients. Medications commonly used were propofol, midazolam, morphine, and fentanyl. There were 135 situations of adverse events, which related to patients pulling endotracheal tubes leading to malpositioning, patients biting endotracheal tubes causing desaturation, patient experiencing excessive agitation requiring restraint use, patients experiencing increased intracranial pressure above desired limits, patients self-extubating, and patients experiencing over-drowsiness leading to delays in extubation.

Conclusions

Many patients were either very sedated or agitated at some point during the study period, and some patients experienced adverse outcomes associated with sedation practices. The findings inform future quality initiatives to improve sedation practices.

Section snippets

Introduction and background

Adequate sedation is crucial for the recovery of patients in intensive care units (ICUs). In essence, sedation is the process of depressing the patients’ awareness of the environment and reducing their response to external stimulation. It has a wide spectrum of symptom control that varies between patients, and among patients throughout the course of their illness (Rowe & Fletcher, 2008). The main goals of sedation are that patients are calm, co-operative and comfortable. These goals can be

Research design

This study utilised a retrospective clinical audit design. Ethics approval was obtained by the human research ethics committee of the hospital.

Population, sampling and data collection

The sample was a whole population sample of the medical records of patients admitted to an ICU of an Australian metropolitan, teaching hospital over a 12-month period. The ICU was a Level III, tertiary referral unit, which had 24 intensive care and high dependency beds. Inclusion criteria involved patients who were admitted to the ICU between the 1st of

Demographics

Data were extracted from medical records of 150 patients for the 12-month period (Table 1 and Fig. 1). Of these patients, 63% of the sample was male. The median age was 60 years (interquartile range (IQR) = 39.0–71.3 years). The most frequent admitting diagnoses to the hospital were of a neurological (n = 46/150, 30.6%) or cardiovascular (n = 34/150, 22.7%) nature. The median duration of ICU stay was 10.0 days (IQR = 8.0–15.0 days), and the median duration of hospital stay was 25.0 days (IQR = 16.8–41.3

Discussion

The study provided important new knowledge about sedation practices in an Australian ICU. Patients were shown to be either unarousable or very sedated between 57% and 81% at some point during the study period, while between 5% and 11% were agitated, very agitated or extremely agitated across this time. Furthermore, some patients experienced adverse events relating to sedation practices, including desaturation from biting endotracheal tubes, the use of limb restraints, self-extubation, high

Conclusions

The study showed that more than half the patients were either unarousable or very sedated, or agitated or very agitated for a large proportion of the study period. Fewer than half the patients were either calm or cooperative, or moderately sedated during this time.

Recommendations for policy, practice, education and research arise from this study. Hospital policies should provide information about how to associate sedation scores with goals of care, and how various sedatives and analgesics

Acknowledgements

The authors wish to thank the staff members of the Health Information Services Department, who were particularly helpful in accessing medical records required for the study. Many thanks go to the health professionals who participated in content validity testing of the Sedation Audit Tool. The authors received no financial support in the conduct of this research.

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