Implementation of a sedation protocol: a quality improvement project to enhance sedation management in the paediatric intensive care unit

BackgroundProper sedation is integral to ensuring the safety and comfort of children on mechanical ventilation (MV). Sedation protocols help to achieve this goal and reduce the duration of MV. We have observed varied sedation approaches, sedation score targets and sedative use by our physicians, which were manifested as oversedation and undersedation with associated accidental extubation. Hence, we aimed to implement a standardised sedation protocol and assess its impact on mechanically ventilated paediatric patients.MethodsA multidisciplinary quality improvement team was formed to develop and implement a standardised sedation protocol for mechanically ventilated paediatric patients. COMFORT-Behaviour (COMFORT-B) Scale score was used to assess the sedation targets and define undersedation, oversedation or adequate sedation. Our goal was to achieve adequate sedation during 90% of the sedation period. Based on the model for improvement methodology, we used plan–do–study–act cycles to develop, test and implement the new sedation protocol.ResultsThere was an immediate percentage increase in COMFORT-B Scale scores within the target sedation level, which was associated with a gradual decrease in the need for intermittent sedation doses over sedation infusion in the preimplementation, improvement and control phases (6.3, 4.9 and 3.1 sedation doses/12 hours/patient, respectively) to achieve adequate sedation target.ConclusionsThe standardisation of sedation protocols was safe and efficient, and improved the sedation quality in mechanically ventilated paediatric patients.

Favorable Outcomes After Implementing a Nurse-Driven Sedation Protocol

Background In patients receiving mechanical ventilation, prolonged exposure to sedative and analgesic medications contributes to negative clinical outcomes. Objective To reduce exposure to sedative and analgesic medications among patients receiving mechanical ventilation by implementing a nurse-driven sedation protocol. Methods This quality improvement project followed a plan-do-study-act cycle. Nurses were educated on the protocol, and 30 patient medical records were reviewed both before and after protocol implementation. Data were extracted on intensive care unit length of stay, duration of mechanical ventilation, duration of continuous sedation, presence of delirium, pain, level of sedation, and performance and documentation of spontaneous awakening trials. Data were analyzed using descriptive statistics, the χ2 test, and calculated percent change. Results Forty-four nurses completed protocol education. The mean (SD) duration of mechanical ventilation decreased by 26% (from 5 [3.7] days to 3.7 [3.2] days), and the mean (SD) intensive care unit length of stay decreased by 27% (from 6.3 [4.3] days to 4.6 [3.7] days). The mean (SD) duration of continuous sedation decreased by 35% (from 6419 [7241] minutes to 4178 [4507] minutes). Spontaneous awakening trials documented increased by 35% (from 57% to 77%), and spontaneous awakening trials performed increased by 92% (from 40% to 77%), a statistically significant change (P = .004). Conclusion These preliminary data suggest that implementation of a nurse-driven sedation protocol resulted in favorable outcomes by decreasing duration of mechanical ventilation, intensive care unit length of stay, and duration of continuous sedation and increasing the number of spontaneous awakening trials performed.

Tools Are Needed to Promote Sedation Practices for Mechanically Ventilated Patients

Suboptimal sedation practices continue to be frequent, although the updated guidelines for management of pain, agitation, and delirium in mechanically ventilated (MV) patients have been published for several years. Causes of low adherence to the recommended minimal sedation protocol are multifactorial. However, the barriers to translation of these protocols into standard care for MV patients have yet to be analyzed. In our view, it is necessary to develop fresh insights into the interaction between the patients' responses to nociceptive stimuli and individualized regulation of patients' tolerance when using analgesics and sedatives. By better understanding this interaction, development of novel tools to assess patient pain tolerance and to define and predict oversedation or delirium may promote better sedation practices in the future.

Safety and Efficacy of Pediatric Sedation Protocols for Painless Diagnostic Examination in A Pediatric Emergency Room of A Single Tertiary Hospital

Background: Pediatric patients undergoing diagnostic tests in the pediatric emergency room are frequently sedated. Although efforts are made to prevent adverse events, no sedation protocol has specified the optimal regimen, dosage, and interval of medication to prevent adverse events. This study analyzed the safety and efficacy of sequential pediatric sedation protocols for pediatric patients undergoing diagnostic tests in the pediatric emergency room of a single tertiary medical center.Methods: The medical records of patients aged <18 years who visited the pediatric emergency room of Seoul Asan Medical Center between January and December 2019 for diagnostic testing were retrospectively reviewed. Sedation protocols consisted of 50 and 25 mg/kg chloral hydrate, 0.1 and 0.1 mg/kg midazolam, and 1 and 0.5–1 mg/kg ketamine, administered sequentially at intervals of 30, 20, 10, 10, and 10 min, respectively. Patients were assessed prior to sedation, and adverse events were investigated.Results: Of the 289 included patients, 20 (6.9%) experienced adverse events, none serious, and nine (3.1%) failed to reach the depth of sedation required to complete the test. The regimen (P=0.622) and dosage (P=0.777) of the sedatives were unrelated to the occurrence of adverse events when sedation was performed according to protocol.Conclusion: The sedation protocol used in these patients, consisting of sequential administration of minimum dosages, achieved a sufficient depth of sedation with relatively few adverse events, indicating that this protocol can be used safely and effectively for painless sedation in pediatric patients undergoing diagnostic testing.