Predictors for daily interruption of sedation therapy by nurses: a prospective, multicenter study.
ABSTRACT The aim of the study was to identify the nurse and patient-related factors predicting daily interruption of sedation (DIS) performance by nurses in the intensive care unit (ICU).
Nurses, caring for a mechanically ventilated patient receiving 24 hours or more of a continuously infused sedative, were interviewed at the bedside to determine their willingness to perform DIS on this patient and to determine the influence of 20 nurse- and 47 patient-related factors on DIS completion.
The 57 (44%) of 130 of nurses willing to perform DIS had performed DIS at least once in the past (P < .0001) and were not targeting deep sedation (ie, Sedation Agitation Scale [SAS] ≤ 2 [P = .03]). The DIS performance was less likely with use of higher-dose continuous midazolam (P = .006), a fraction of inspired oxygen (Fio(2)) greater than 50% (P = .03), or positive end-expiratory pressure greater than 5 mm Hg (P = .006) and in patients either deeply sedated (SAS ≤ 2) (P = .05) or agitated (SAS ≥ 5) in the past 24 hours (P = .003). Prior DIS experience (odds ratio [OR], 2.54; P = .004), hours of sedation-related continuing education (OR, 1.13; P = .02), and a target of deep sedation (OR, 0.49; P = .02) were independent nurse-related factors for DIS performance. Nurse's willingness to conduct DIS ranged from 45% to 80% based on the interaction between patient sex, current Fio(2), and agitation in past 24 hours.
Educational strategies and institutional protocols focused on improving use of DIS need to consider the various nurse- and patient-related factors that affect DIS performance by nurses in the ICU.
- SourceAvailable from: Louise Rose
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- "For patients assigned to the DI group, respondents were asked the additional question " I was concerned for my patient during DI due to the risk of… " and were provided with 6 categorical options as well as the opportunity for a textual response . We included this question to assess perceived safety concerns regarding DI that were raised by clinicians in previous studies     "
ABSTRACT: Within a multicenter randomized trial comparing protocolized sedation with protocolized sedation plus daily interruption (DI), we sought perspectives of intensive care unit (ICU) clinicians regarding each strategy. At 5 ICUs, we administered a questionnaire daily to nurses and physicians, asking whether they liked using the assigned strategy, reasons for their responses, and concerns regarding DI. A total of 301 questionnaires were completed, for 31 patients (15 protocol only and 16 DI); 117 (59 physicians and 58 nurses) were the first questionnaire completed by that health care provider for that patient and were included in analyses. Most respondents liked using the assigned strategy (81% protocol only and 81% DI); more physicians than nurses liked DI (100% vs 61%; P < .001). Most common reasons for liking the assigned sedation strategy were better neurologic assessment (70% DI), ease of use (58% protocol only), and improved patient outcomes (51% protocol only and 44% DI). Only 19% of clinicians disliked the assigned sedation strategy (equal numbers for protocol only and DI). Respondents' concerns during DI were respiratory compromise (61%), pain (48%), agitation (45%), and device removal (26%). More questionnaires from nurses than physicians expressed concerns about DI. Most respondents liked both sedation strategies. Nurses and physicians had different preferences and rationales for liking or disliking each strategy. Copyright © 2014 Elsevier Inc. All rights reserved.Journal of Critical Care 10/2014; 30(2). DOI:10.1016/j.jcrc.2014.10.021 · 2.19 Impact Factor
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ABSTRACT: To measure the impact of a national propofol shortage on the duration of mechanical ventilation. Before-after study. Three, noncardiac surgery, adult intensive care units at a 320-bed academic medical center. Consecutive patients requiring mechanical ventilation ≥48 hrs, administered a continuously infused sedative ≥24 hrs, extubated, and successfully discharged from the intensive care unit were compared between before (December 1, 2008 to May 31, 2009) and after (December 1, 2009, to May 31, 2010) a propofol shortage. None. Sedation drug use and common factors affecting time on mechanical ventilation were collected and if found either to differ significantly (p ≤ .10) between the two groups or to have an unadjusted significant association (p ≤ .10) with time on mechanical ventilation were included in a multivariable model. The unadjusted analyses revealed that the median (interquartile range) duration of mechanical ventilation increased from 6.7 (9.8; n = 153) to 9.6 (9.5; n = 128) days (p = .02). Fewer after-group patients received ≥24 hrs of continuously infused propofol (94% vs. 15%, p < .0001); more received ≥24 hrs of continuously infused lorazepam (7% vs. 15%, p = .037) and midazolam (30% vs. 81%, p < .0001). Compared with the before group, the after group was younger, had a higher admission Acute Physiology and Chronic Health Evaluation II score, was more likely to be admitted by a surgical service, have acute alcohol withdrawal, and be managed with pressure-controlled ventilation as the primary mode of mechanical ventilation. Of these five factors, only the Acute Physiology and Chronic Health Evaluation II score, admission service, and use of a pressure-controlled ventilation affected duration of mechanical ventilation across both groups. Although a regression model revealed that Acute Physiology and Chronic Health Evaluation II score (p < .0001), admission by a medical service (p = .009), and use of pressure-controlled ventilation (p = .02) each affected duration of mechanical ventilation in both groups, inclusion in either the before- or after-propofol shortage groups (i.e., high vs. low use of propofol) did not affect duration of mechanical ventilation (p = .35). An 84% decrease in propofol use in the adult intensive care units at our academic institution as a result of a national shortage did not affect duration of mechanical ventilation.Critical care medicine 09/2011; 40(2):406-11. DOI:10.1097/CCM.0b013e31822f0af5 · 6.15 Impact Factor
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ABSTRACT: more quickly from mechani-cal ventilation, with lower risk of delirium, when clini-cians use specific strategies to reduce excessive sedation. 1-3 A nursing-implemented sedation titration proto-col that specifies clear targets for level of awareness is one approach to mini-mize sedation. 4 Daily interruption of sedative infusions may achieve the same goal if infusions are resumed only when necessary and at half theJournal of the American Medical Association 10/2012; 308(19). DOI:10.1001/jama.2012.13872