Sedation Vacation Jennifer Aguirre Ray Alvarado Brita Furr

Sedation Vacation Jennifer Aguirre, Ray Alvarado, Brita Furr, Emilee Hawk, Leann Huso, Diana Hess, Crystal Maciel, Hannah Ridinger, Janelle Westbrook, S

What is sedation vacation? S Hold the sedation and opioid infusion each day until the patient wakes up and can follow simple commands S Restarted at predetermined dose according to protocol if necessary for maintenance of patient comfort, and then titrated accordingly S Goals of sedation vacation S Optimize sedation and analgesic therapy S Guide titration of therapy to maintain a pain-free and arousable state S Avoid oversedation of patients (Kher et al. , 2012; Mehta S. , 2012)

PICOT Question S (P) In adult ICU patients (T) that are mechanically ventilated for more than 24 hours, (I) does sedation vacation (O) result in better outcomes, including shorter mechanical ventilation duration and reduced length of intensive care unit (ICU) stay, (C) compared to continuous sedation?

Our Ultimate Goal S Our ultimate goal of sedation vacation is to reduce length of stay, decrease incidence of ventilated associated pneumonia, and shorten mechanical ventilation duration by providing education and rounding teams to increase sedation vacation compliance rates.

Summary of Current Practice Criteria for patient eligibility for sedation vacation S Spontaneous Awakening Trials Safety Screen S No active seizures S No alcohol withdrawal S No agitation S No paralytics S No myocardial ischemia S No increased intracranial pressure At hospital X, this is not currently implemented on a consistent basis. (American Association of Critical Care Nurses, 2011)

Does sedation vacation help? S It reduces the number of days of mechanical ventilation and does not adversely affect patient comfort, safety, or post-ICU psychological health S It reduces the likelihood of ventilator associated events per mechanical ventilator episode (pneumonia, acute respiratory distress syndrome, thromboembolisms, pulmonary edema, atelectasis and delirium) S Ventilator associated event’s (VAE) increase patient length of stay and patient mortality (Kher et al. , 2012; Klompas et al. , 2015).

Does sedation vacation help? S Reducing sedation levels during daytime results in increased levels of Rapid Eye Movement (REM) and slow wave sleep, and use of less medication for pain and anesthesia S REM and slow wave sleep are associated with improved rates of healing S Less use of pain and sedation medication results in lower costs to the patient and hospital S Sedative exposure may be one factor that leads to the adverse cognitive outcomes now recognized to occur in a significant portion of ICU survivors (Jackson et al. , 2010; Oto et al. , 2011 )

Is it being implemented? S Compliance rate of 54 -72% S Studies that used observations or chart audits had lower compliance rates compared to studies that used selfreporting as the main measure. (Mendez et al. , 2013; Mehta et. al, 2012; Ackrivo et al, 2015; Miller et al. , 2012)

Why is there noncompliance? S Institutional and unit culture S Staff receptivity to change S Patient discomfort S Possibility of patient experiencing respiratory distress S Patient safety S Possibility of patient-initiated device removal (Hogue & Mamula, 2013; Kher et al. , 2012; Mehta et. al, 2012; Miller et al. , 2012)

Why is there noncompliance? S The level of knowledge and skill may be different between nurses S Assessments and performances of sedation vacation may be inaccurate S Additional workload for nurses (Ackrivo et al, 2015)

How to change nurse’s perceptions? S Clarify to staff that common perceptions about sedation vacation are not evidence based S Staff should be encouraged to use other means of calming patients without giving additional sedatives S Educate ICU team about national sedation guidelines and the importance of adhering to them S Provide protocols for the staff and educate the nurses on how to implement sedation vacation (Ackrivo et al, 2015; Khan et al. , 2014; Kher et al. , 2012; Klompas et al. , 2015)

How to change nurse’s perceptions? S Educate staff about the benefits of targeted light sedation S Sedative medications may contribute to adverse psychological outcomes S Some patients who experience sedative-induced delusions while in the ICU, are more likely to develop PTSD than patients who have factual memories of their ICU stay (Jackson et al. , 2010; Mehta, 2012)

How to Increase Compliance Rates S A dedicated interdisciplinary rounding team: S attending physician, nursing unit leader, respiratory therapist, and a pharmacist S Round the unit every weekday morning at 0800 S Was it performed? S Provide immediate feedback to the nurse if incompliant (Kher et al. , 2012)

How to Increase Compliance Rates S Use of “triggers” to prompt nurses to complete sedation vacation S Integration of a structured protocol to enhance implementation S coordinates spontaneous breathing trials, delirium management, and early mobilization (Kher et al. , 2012; Miller et al. , 2012)

Strengths of Current Research S Most of the studies had large sample sizes and were conducted over several months. S Diverse healthcare settings S They took ethnicity, sex, and age into consideration. S The findings and results from the articles were congruent. (Khan et al. , 2014; Klompas et al. , 2015; Mehta S. , 2012; Mendez et al. , 2013; Ackrivo et al. , 2015; Oto et al. , 2011)

Weaknesses of Current Research S Majority of studies were not randomized controlled studies. S Not randomized or blinded because of nature of intervention. S No standardized measurement of compliance. S Biases were possibilities in several studies S Hawthorne Effect S Research studies depended on self reporting ~ documentation. (Ackrivo et al, 2015; Khan et al. , 2014; Mendez et al. ; Miller et al. , 2012; Oto et al. , 2011)

EBP Recommendation #1 S Providing automatically generated reminders to nurses for daily sedation vacation. S Implementation: Generate an order/task to be included for all continuously-sedated patients to complete sedation vacation at a scheduled time each day, unless the patient meets the pre-determined exclusion criteria. Research shows that triggers to remind the nurse of sedation vacation increases compliance rates. S (Kher et al. , 2013; Klompas et al. , 2015)

EBP Recommendation #2 S Encouraging increased accountability for adherence to daily sedation vacation protocol. S Implementation: Include a section within Cerner that requires completion of documentation of sedation vacation, and requiring nurses to provide a reason for not completing the sedation vacation, if applicable. Research shows that requiring measurement and reporting of actual performance of sedation vacation increased rates of adherence to daily sedation vacation. S (Kher et al. , 2013; Klompas et al. , 2015)

EBP Recommendation #3 S Encouraging compliance by utilizing an interdisciplinary team to evaluate nurse adherence to completion of daily sedation vacation. S Implementation: During interdisciplinary rounding, the nurse will inform the members of the dedicated rounding team whether or not each eligible mechanically ventilated patient is receiving the required sedation vacation. If the nurse is not complying with the hospital policy, the charge nurse is responsible for addressing the nurse’s noncompliance with sedation vacation. Research shows that a multi-disciplinary team approach increased compliance rates of daily sedation vacation and provided immediate feedback to the nurses. S (Kher et al. , 2013; Mendez et al. , 2013; Miller et al. , 2012)

EBP Recommendation #4 S Educating nurses about the evidence-based research regarding sedation vacation, including evaluation of the patient’s eligibility for sedation vacation. S Implementation: Institution of a mandatory online module that educates nurses about the benefits of daily sedation vacations and addresses the misperceptions and concerns of the nurses regarding sedation vacation. Research shows that by increasing the knowledge of how and when to implement sedation vacation, nurse compliance rates increase. S (Ackrivo et al. , 2015; Kher et al. , 2013; Klompas et al. , 2015; Miller et al. , 2012)

SMART Outcomes S Chart audits performed on the last day of each month will show an increase in compliance rates from the previous month’s compliance rate of 10% up to a goal rate of at least 90%. S Every morning by 11: 00 AM, the multidisciplinary team involved with ensuring the patient is receiving the required sedation vacation will have rounded and documented the occurrence as a progress note after the encounter. S Every year, a nurse will complete the mandatory online module, and obtain a certification of completion that will be added to their employee profile.

Evaluations of Outcomes S Not Implemented – It is likely that implementation of daily reminders would result in increased rates of compliance. S Not Implemented – It is likely that implementation of a rounding team would increase the nurse’s accountability for adherence to daily sedation vacation. S Not Implemented – It is likely that scheduling mandatory online modules that provide nurses with knowledge concerning benefits and the proper implementation of sedation vacation will increase rates of compliance.

Patient’s Risk vs. Benefit S Benefits: S Lowers risk of VAP (Ventilator Associated Pneumonia) S Lowers risk of delirium S Lowers incidence of PTSD S Decreases length of hospital stay S Increases level of REM and slow-wave sleep, which are associated with improved rates of healing. S Reduces pain medication S Decreases exposure to sedatives and their side effects S Risks: S Feelings of discomfort, pain, agitation (Klompas et al. , 2015; Mendez et al. , 2013; Jackson et al. , 2010; Mehta et al. , 2012; Kher et al. , 2012; Oto et al. , 2011; Dotson, 2010)

Nurse’s Risk vs. Benefit S Benefit: S Ability to titrate sedation accurately. S Multidisciplinary resources and support for nurse. S Risk: S Increases nurse workload. (Kher et al. , 2012; Varshney, 2013; Dotson, 2010; Mehta et. al, 2012)

Hospital’s Risk vs. Benefit S Benefit: S S VAP incidence is decreased. VAP’s are a never event. Incidence of tracheostomies was reduced. Low rate of re-intubations. Risk: S S There is no guarantee that the money spent on recommended guidelines will increase nurse compliance. Patients may extubate themselves once on light sedation Increased costs of sedation because larger doses may be needed to re-sedate patients. Is there money spent on recommendations than saved from recommendations? (Pulm. CCM, 2014; Klompas et al. , 2015; Mendez et al. , 2013)

Cost of Implementation S Online Education Workshop Module ~ 1 Hour Module S Cost of creating a module S S The average rate is $116 per hour X 383 hours of development for a 1 hour module Total Cost ~ $44, 428 S Updating Cerner S New task S document section in nursing flowsheet S Dedicated Interdisciplinary Team: S There will be an increased cost associated with scheduling more personnel to specifically round on sedated patients. (Bureau of Labor Statistics, 2014; Karrer, 2009)

Cost-Saving Effects of Implementation S Decreases patient length of stay in the ICU by three days S One day in ICU on mechanical ventilation costs $6, 324 S An incidence of VAP can increase hospital costs by $40, 000 per stay, per patient S Daily sedation vacation can lead to decreased use of pain and sedative medications S Costs are higher in patients who experience delirium than in those patients who do not S On average, delirium in the ICU costs $22, 346 versus a cost of $13, 332 in patients who did not experience it. (Critical Care Societies Collaborative, n. d. ; Dotson, 2010; Huynh et al. , 2013; Klompas et al. , 2015; Oto et al. , 2011)

Summary S (P) In adult ICU patients (T) that are mechanically ventilated for more than 24 hours, (I) does sedation vacation (O) result in better outcomes, including shorter mechanical ventilation duration and reduced length of intensive care unit (ICU) stay, (C) compared to continuous sedation? S Is it being performed? S Compliance: S Need for education and improved working environment S What we can do to fix it? S Cost S S What the hospital saves Implementation

References S Ackrivo, J. , Horbowicz, K. J. , Mordino, J. , El Kherba, M. , Ellingwood, J. , Sloan, K. , & Murphy, J. (2015). Successful implementation of an automated sedation vacation process in intensive care units. American Journal of Medical Quality: The Official Journal of the American College of Medical Quality, doi: 1062860615593340 S Bureau of Labor Statistics (2014). Occupational Outlook Handbook: Registered Nurses. U. S. Department of Labor. Retrieved 23 October 2015 from http: //www. bls. gov/ooh/healthcare/registered-nurses. htm S Critical Care Societies Collaborative. (n. d. ). VAE. In Critical Care Societies Collaborative. Retrieved October 21, 2015, from http: //ccsconline. org/ventilator-associated-pneumonia S Dotson B. (2010). Daily interruption of sedation in patients treated with mechanical ventilation. American Journal of Health-System Pharmacology 67(2), 1002 -1006. S Hogue, M. D. , & Mamula, S. (2013). Sedation vacation: Worth the trip. Nursing 2015 Critical Care 8(1), 3537. S Huynh TN, Kleerup EC, Wiley JF, et al. The Frequency and Cost of Treatment Perceived to Be Futile in Critical Care. JAMA Intern Med. 2013; 173(20): 1887 -1894. doi: 10. 1001/jamainternmed. 2013. 10261 S Jackson, D. L. , Proudfoot, C. W. , Cann, K. F. , Walsh, T. (2010). A systematic review of the impact of sedation practice in the ICU on resource use, costs and patient safety. Crit Care. 14: R 59.

References Continued S Jackson, J. C. , Girard, T. D. , Gordon, S. M. , Thompson, J. L. , Shintani, A. K. , Thomason, J. W. , . . . Ely, E. W. (2010). Long-term cognitive and psychological outcomes in the awakening and breathing controlled trial. American Journal of Respiratory and Critical Care Medicine, 182(2), 183 -191. doi: 10. 1164/rccm. 200903 -0442 OC S Karrer, T. (2009). E-learning costs. Retrieved from elearning. com S Khan, B. A. , Fadel, W. F. , Tricker, J. L. , Carlos, W. G. , Farber, M. O. , Hui, S. L. , . . . Boustani, M. A. (2014). Effectiveness of implementing a wake up and breathe program on sedation and delirium in the ICU. Critical Care Medicine, 42(12), e 791 -5. doi: 10. 1097/CCM. 0000000660 S Kher, S. , Roberts, R. J. , Garpestad, E. , Kunkel, C. , Howard, W. , Didominico, D. , . . . Devlin, J. W. (2013). Development, implementation, and evaluation of an institutional daily awakening and spontaneous breathing trial protocol: A quality improvement project. Journal of Intensive Care Medicine, 28(3), 189 -197. doi: 10. 1177/0885066612444255 S Klompas, M. , Anderson, D. , Trick, W. , Babcock, H. , Kerlin, M. P. , Li, L. , . . . CDC Prevention Epicenters. (2015). The preventability of ventilator-associated events. the CDC prevention epicenters wake up and breathe collaborative. American Journal of Respiratory and Critical Care Medicine, 191(3), 292 -301. doi: 10. 1164/rccm. 201407 -1394 OC S Mehta, S. , Burry, L. F. , Cook, D. F. , Fergusson, D. F. , Steinberg, M. F. , Granton, J. F. , . . . Meade, M. (2012). Daily sedation interruption in mechanically ventilated critically ill patients cared for with a sedation protocol: A randomized controlled trial. The Journal of the American Medical Association, 308 (19). doi: 10. 1001/jama. 2012. 13872

References Continued S Mendez, M. P. , Lazar, M. H. , Digiovine, B. , Schuldt, S. , Behrendt, R. , Peters, M. , & Jennings, J. H. (2013). Dedicated multidisciplinary ventilator bundle team and compliance with sedation vacation. American Journal of Critical Care : An Official Publication, American Association of Critical-Care Nurses, 22(1), 5460. doi: 10. 4037/ajcc 2013873 [doi] S Miller, M. A. , Krein, S. L. , Saint, S. , Kahn, J. M. , & Iwashyna, T. J. (2012). Organizational characteristics associated with the use of daily interruption of sedation in US hospitals: A national study. BMJ Quality and Safety, 21(2), 145 -151. doi: 10. 1136/bmjqs-2011 -000233 S Oto, J. , Yamamoto, K. , Koike, S. , Imanaka, H. , & Nishimura, M. (2011). Effect of daily sedative interruption on sleep stages of mechanically ventilated patients receiving midazolam by infusion. Anaesthesia and Intensive Care, 39(3), 392 -400. S Pulm. CCM. (2014). Do "Sedation Vacations" Really Speed Weaning From Mechanical Ventilation? . Retrieved from http: //pulmccm. org/main/2013/randomized-controlled-trials/sedation-vacations-dont-reduce -ventilator-or-icu-days-in-large-trial-rct-jama/ S Varshney, U. (2013). Smart medication management system and multiple interventions for medication adherence. Retrieved from http: //www. sciencedirect. com/science/article/pii/S 0167923612002667