DOES DAILY TRACKING IMPROVE CONCORDANCE?

Sedation and Analgesia Protocols in a Community-

Based Intensive Care Unit

Richard Nadeau, BMSc1

Robert J Anderson, MD FRCPC1,2

David Boyle, MD FRCPC1,2

1Northern Ontario School of Medicine2Hôpital régional de Sudbury Regional Hospital (HRSRH)

Department of Anaesthesia and Critical Care Medicine

Funding and Disclosure

Funding for this project provided by the Northern Ontario School of Medicine

Founding Dean Summer Medical StudentResearch Award (2009)

No conflicts of interest to disclose (all authors)

From Theory to Practice

Protocolized Sedation during MV

Brook et al, CCM 1998; 27 (12): 2609-15

Daily SAT

Kress et al, NEJM 2000; 342: 1471-7

Pairing SAT and SBT (ABC Trial)

Girard et al, Lancet 2008; 371: 126-34

Titrating to the Sedation Analgesia Scale

“A sedation goal or endpoint should be established and regularly redefined for each patient. Regular assessment and response to

therapy should be systematically documented.”(Grade of recommendation = C)

“The use of a validated sedation assessment scale (SAS, MAAS, or VICS) is recommended.”

(Grade of recommendation = B)

Jacobi et al. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. CCM 2002; 30 (1): 119-41

A Role for the Dedicated ICU Pharmacist?

Marshall et al, CCM 2008; 36 (2): 427-33

Study Design

Hypothesis: Having an auditor present to give daily feedback to the ICU Care Team will improve concordance to the protocol.

Setting: HRSRH Medical/Surgical ICUControl group: Retrospective chart reviewIntervention group: Daily audit and feedback of ICU

Care Team

Primary outcome measure: Concordance in proper utilization of the Protocol

Secondary outcome measures: Duration of mechanical ventilation (days) Amount of sedative administered

Propofol, BZD, opioids, ketamine and haloperidol

Concordance?

Protocol Ordered?

Yes No

Protocol Indicated?Yes

Concordant Discordant

NoDiscordant Concordant

IMPLEMENTED EACH STEP AS PER PROTOCOL?

YES NO

Concordant Discordant

Ordering the Protocol

n=149 n=72# ventilator days

Ordering and Implementing the Protocol

n=149

n=72

n=14

n=12

***p = 0.0002***p = 0.0002

# ventilator days

# concordant days

Implementing the Protocol

*p = 0.0163*p = 0.0163

n=95

n=51

# days Protocol ordered

Clinical Outcomes

Secondary Outcome Measure Control Intervention p value

Number of patients 32 23

Number of ventilator days 149 72

Ventilator duration (days), mean ± SD

4.14 ± 4.95 3.34 ± 2.81 0.4889

Propofol (mg/day), mean ± SD 2640.90 ± 2318.33 2294.40 ± 1530.11 0.2809

Lorazepam eq (mg/day), mean ± SD

14.82 ± 23.29 9.41 ± 9.76 0.2933

Fentanyl eq (mg/day), mean ± SD 542.53 ± 1092.64 576.35 ± 749.26 0.8637

Ventilator-associated pneumonia, n (%)

2 (5.56%) 1 (4.35%) 1.000

Venous thromboembolism, n (%) 1 (2.78%) 0 (0.00%) 1.000

Mortality, n (%) 9 (25.00%) 3 (13.04%) 0.3341

Conclusions and Discussion

Baseline concordance not very goodModest benefit of having auditor present

Improved ICU Care Team concordance when Protocol is ordered

Better sedative titration as per SAS

Is there a place for dedicated ICU pharmacist in a community-based ICU?

Limitations

Acknowledgments

Dr. Rob Anderson

All members of the ICU Care Team

Northern Ontario School of Medicine

QUESTIONS?QUESTIONS?