I-SAVE Study: Impact of Sedation, Analgesia and Delirium Protocols Evaluated in the Intensive Care Unit: An Economic Evaluation

Pharmacy Department, Maisonneuve-Rosemont Hospital, Montreal, Quebec, Canada.
Annals of Pharmacotherapy (Impact Factor: 2.06). 12/2011; 46(1):21-8. DOI: 10.1345/aph.1Q284
Source: PubMed


Intensive care units (ICUs) account for considerable health care costs. Adequate pain and sedation management is important to clinical care.
To determine whether implementing a protocol for management of analgesia, sedation, and delirium in the ICU would save costs.
With data from the I-SAVE (Impact of Sedation, Analgesia and Delirium Protocols Evaluated in the Intensive Care Unit: an Economic Evaluation) study, a prospective pre- and postprotocol design was used. Between the 2 periods, protocols for systematic management of sedation, analgesia, and delirium were implemented. Cost-effectiveness was calculated by associating the variation of cost and effectiveness measures (proportion of patients within targeted pain, sedation, and delirium goals). Total costs (in 2004 Canadian dollars), by patient, consisted of the sum of sedation, analgesia, and delirium drug acquisition costs during the ICU stay and the cost of the ICU stay.
A total of 1214 patients, 604 in the preprotocol group and 610 in the postprotocol group, were included. The mean (SD) ICU length of stay and the duration of mechanical ventilation were shorter among patients of the postprotocol group compared with those of the preprotocol group (5.43 [6.43] and 6.39 [8.05] days, respectively; p = 0.004 and 5.95 [6.80] and 7.27 [9.09] days, respectively; p < 0.009). The incidence of delirium remained the same. The proportion of patients with Richmond Agitation and Sedation (RASS) scores between -1 and +1 increased from 57.0% to 66.2% (p = 0.001), whereas the proportion of patients with a numeric rating scale (NRS) score of 1 or less increased from 56.3% to 66.6% (p < 0.001). The mean total cost of ICU hospitalization decreased from $6212.64 (7846.86) in the preprotocol group to $5279.90 (6263.91) in the postprotocol group (p = 0.022). The cost analyses for pain and agitation management improved; the proportion of patients with RASS scores between -1 and +1 or NRS scores of 1 or less increased significantly in the postprotocol group while costing, on average, $932.74 less per hospitalization.
Establishing protocols for patient-driven management of sedation, analgesia, and delirium is a cost-effective practice and allows savings of nearly $1000 per hospitalization.

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Available from: Yoanna Skrobik, Jan 31, 2014
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    • "The present study showed that the investigated managed protocol for severe sepsis and septic shock management is cost-effective. The protocol can be compared with other protocols that apply to interventions for acute situations [23] [24] [25] [26], and it resulted in a gain of life-years in this population of patients with severe sepsis. Therefore, managed protocols for the treatment of patients with severe sepsis are fully indicated. "
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    ABSTRACT: Purpose Severe sepsis is a time-dependent disease, and implementation of early treatment has been associated with mortality rate reduction. However, the literature is controversial regarding cost-effectiveness analysis of this intervention. The aim was to assess the cost-effectiveness of a managed protocol for the treatment of severe sepsis. Materials and methods This is a prospective cohort study involving a historical comparison (before and after the implementation of the protocol) of patients who had been hospitalized with severe sepsis and septic shock. The group of patients who were treated before the assistance routine was implemented was considered to be the control. The case managed nurse involved with assistance protocol performed the data collection. This nurse received special training to ensure the quality of the data and to measure the intervention throughout the implementation process. Results A total of 414 patients were analyzed. The mortality rates were 57% in the control group and 38% in the protocol group (p = 0.002). After the implementation of the protocol, the absolute risk reduction was 18%, and the relative risk reduction was 31.8%. There was a tendency for a reduction in the cost of the full hospitalization, but this trend did not reach statistical significance. Nevertheless, the cost of hospitalization in the intensive care unit (ICU) reduced significantly from US$ 138,237 ± 202,418 in the control group to US$ 85,484 ± 127,471 in the protocol group (p = 0.003). The managed protocol for sepsis resulted in an average gain of 3.2 life-years after being discharged from the hospital (8.8 ± 13.3 years in the control group and 12.0 ± 14.0 years in the protocol group; p = 0.01). Conclusions Given the incremental cost was lower than or equal to zero, the effectiveness of the protocol was justified by the significant increase in the life-years saved and the reduced mortality.
    Full-text · Article · Aug 2014 · Journal of Critical Care
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    • "As these guidelines point out, improved pain management is clearly associated with better patient outcome in the ICU [8,18,19]. At least three studies performed in surgical, trauma, and medical ICUs report that a protocolized approach to assess and manage pain, agitation, and delirium [20] is associated with a reduced duration of mechanical ventilation, ICU acquired infections, length of stay and costs in ICU, and hospital as well as 30-day mortality [8,18-21]; accordingly, the guidelines recommend protocolized pain screening and assessing analgesic needs first to palliate the current under-recognition and treatment of pain [22]. "
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    ABSTRACT: The recently published Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit differ from earlier guidelines in the following ways: literature searches were performed in eight databases by a professional librarian; psychometric validation of assessment scales was considered in their recommendation; discrepancies in recommendation votes by guideline panel members are available in online supplements; and all recommendations were made exclusively on the basis of evidence available until December of 2010. Pain recognition and management remains challenging in the critically ill. Patient outcomes improve with routine pain assessment, use of co-analgesics and administration as well as dose adjustment of opiates to patient needs. Thoracic epidurals help ease patients undergoing abdominal aortic surgery. Little data exists to guide clinicians as to the type or dose of co-analgesics; no opiate choice is associated with better patient outcomes. Lighter or no sedation is beneficial, and interruption is desirable in patients who require deep sedation for specific pathologic states. Delirium screening is probably useful; no treatment modality can be unequivocally recommended, and the benefit of prophylaxis is established only for early mobilization. The details of these recommendations, as well as more recent publications that complement the guidelines, are provided in this commentary.
    Full-text · Article · Apr 2013 · Annals of Intensive Care
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    • "However, there is evidence that when delirium screening is applied as part of a broader protocol initiative that includes active management of sedatives and analgesics as well as nonpharmacological measures, such as music and reassurance, several clinical benefits may ensue, such as shorter duration of mechanical ventilation, lower ICU and hospital stay, and lower 30-day mortality [49]. The protocol also is associated with cost savings [50]. "
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    ABSTRACT: Delirium is characterized by a disturbance of consciousness with accompanying change in cognition. Delirium typically manifests as a constellation of symptoms with an acute onset and a fluctuating course. Delirium is extremely common in the intensive care unit (ICU) especially amongst mechanically ventilated patients. Three subtypes have been recognized: hyperactive, hypoactive, and mixed. Delirium is frequently undiagnosed unless specific diagnostic instruments are used. The CAM-ICU is the most widely studied and validated diagnostic instrument. However, the accuracy of this tool may be less than ideal without adequate training of the providers applying it. The presence of delirium has important prognostic implications; in mechanically ventilated patients it is associated with a 2.5-fold increase in short-term mortality and a 3.2-fold increase in 6-month mortality. Nonpharmacological approaches, such as physical and occupational therapy, decrease the duration of delirium and should be encouraged. Pharmacological treatment for delirium traditionally includes haloperidol; however, more data for haloperidol are needed given the paucity of placebo-controlled trials testing its efficacy to treat delirium in the ICU. Second-generation antipsychotics have emerged as an alternative for the treatment of delirium, and they may have a better safety profile. Dexmedetomidine may prove to be a valuable adjunctive agent for patients with delirium in the ICU.
    Full-text · Article · Dec 2012 · Annals of Intensive Care
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