Improved analgesia, sedation, and delirium protocol associated with decreased duration of delirium and mechanical ventilation

Christopher R. Dale, Delores A. Kannas, Vincent S. Fan, Stephen L. Daniel, Steven Deem, Norbert Yanez, Catherine L. Hough, Timothy H. Dellit, Miriam Treggiari

Research output: Contribution to journalArticle

42 Citations (Scopus)

Abstract

Rationale: Introduction of sedation protocols has been associated with improved patient outcomes. It is not known if an update to an existing high-quality sedation protocol, featuring increased patient assessment and reduced benzodiazepine exposure, is associated with improved patient process and outcome quality metrics. Methods: This was an observational before (n = 703) and after (n = 780) cohort study of mechanically ventilated patients in a 24-bed trauma-surgical intensive care unit (ICU) from 2009 to 2011. The three main protocol updates were: (1) requirement to document Richmond Agitation Sedation Scale (RASS) scores every 4 hours, (2) requirement to document Confusion Assessment Method-ICU (CAM ICU) twice daily, and ( 3 ) systematic, protocolized deescalation of excess sedation. Multivariable linear regression was used for the primary analysis. The primary outcome was the duration of mechanical ventilation. Prespecified secondary endpoints included days of delirium; the frequency of patient assessment with the RASS and CAM-ICU instruments; benzodiazepine dosing; durations of mechanical ventilation, ICU stay, and hospitalization; and hospital mortality and ventilator associated pneumonia rate. Results: Patients in the updated protocol cohort had 1.22 more RASS assessments per day (5.38 vs. 4.16; 95% confidence interval [CI], 1.05-1.39; P <0.01) and 1.15 more CAM-ICU assessments per day (1.49 vs. 0.35; 95% CI, 1.08-1.21; P <0.01) than the baseline cohort. The mean hourly benzodiazepine dose decreased by 34.8% (0.08 mg lorazepam equivalents/h; 0.15 vs. 0.23; P <0.01). In the multivariable model, the median duration of mechanical ventilation decreased by 17.6% (95% CI, 0.6-31.7%; P = 0.04). The overall odds ratio of delirium was 0.67 (95% CI, 0.49-0.91; P = 0.01) comparing updated versus baseline cohort. A 12.4% reduction inmedian duration of ICU stay (95% CI, 0.5-22.8%; P = 0.04) and a 14.0% reduction in median duration of hospitalization (95% CI, 2.0-24.5%; P = 0.02) were also seen. No significant association with mortality (odds ratio, 1.18; 95% CI, 0.80-1.76; P = 0.40) was seen. Conclusions: Implementation of an updated ICU analgesia, sedation, and delirium protocol was associated with an increase in RASS and CAM-ICU assessment and documentation; reduced hourly benzodiazepine dose; and decreased delirium and median durations of mechanical ventilation, ICU stay, and hospitalization.

Original languageEnglish (US)
Pages (from-to)367-374
Number of pages8
JournalAnnals of the American Thoracic Society
Volume11
Issue number3
DOIs
StatePublished - 2014
Externally publishedYes

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Delirium
Artificial Respiration
Analgesia
Intensive Care Units
Confidence Intervals
Benzodiazepines
Hospitalization
Odds Ratio
Lorazepam
Ventilator-Associated Pneumonia
Confusion
Critical Care
Hospital Mortality
Documentation
Linear Models
Cohort Studies
Mortality
Wounds and Injuries

Keywords

  • Critical care
  • Delirium
  • Protocol
  • Quality improvement

ASJC Scopus subject areas

  • Pulmonary and Respiratory Medicine
  • Medicine(all)

Cite this

Improved analgesia, sedation, and delirium protocol associated with decreased duration of delirium and mechanical ventilation. / Dale, Christopher R.; Kannas, Delores A.; Fan, Vincent S.; Daniel, Stephen L.; Deem, Steven; Yanez, Norbert; Hough, Catherine L.; Dellit, Timothy H.; Treggiari, Miriam.

In: Annals of the American Thoracic Society, Vol. 11, No. 3, 2014, p. 367-374.

Research output: Contribution to journalArticle

Dale, Christopher R. ; Kannas, Delores A. ; Fan, Vincent S. ; Daniel, Stephen L. ; Deem, Steven ; Yanez, Norbert ; Hough, Catherine L. ; Dellit, Timothy H. ; Treggiari, Miriam. / Improved analgesia, sedation, and delirium protocol associated with decreased duration of delirium and mechanical ventilation. In: Annals of the American Thoracic Society. 2014 ; Vol. 11, No. 3. pp. 367-374.
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abstract = "Rationale: Introduction of sedation protocols has been associated with improved patient outcomes. It is not known if an update to an existing high-quality sedation protocol, featuring increased patient assessment and reduced benzodiazepine exposure, is associated with improved patient process and outcome quality metrics. Methods: This was an observational before (n = 703) and after (n = 780) cohort study of mechanically ventilated patients in a 24-bed trauma-surgical intensive care unit (ICU) from 2009 to 2011. The three main protocol updates were: (1) requirement to document Richmond Agitation Sedation Scale (RASS) scores every 4 hours, (2) requirement to document Confusion Assessment Method-ICU (CAM ICU) twice daily, and ( 3 ) systematic, protocolized deescalation of excess sedation. Multivariable linear regression was used for the primary analysis. The primary outcome was the duration of mechanical ventilation. Prespecified secondary endpoints included days of delirium; the frequency of patient assessment with the RASS and CAM-ICU instruments; benzodiazepine dosing; durations of mechanical ventilation, ICU stay, and hospitalization; and hospital mortality and ventilator associated pneumonia rate. Results: Patients in the updated protocol cohort had 1.22 more RASS assessments per day (5.38 vs. 4.16; 95{\%} confidence interval [CI], 1.05-1.39; P <0.01) and 1.15 more CAM-ICU assessments per day (1.49 vs. 0.35; 95{\%} CI, 1.08-1.21; P <0.01) than the baseline cohort. The mean hourly benzodiazepine dose decreased by 34.8{\%} (0.08 mg lorazepam equivalents/h; 0.15 vs. 0.23; P <0.01). In the multivariable model, the median duration of mechanical ventilation decreased by 17.6{\%} (95{\%} CI, 0.6-31.7{\%}; P = 0.04). The overall odds ratio of delirium was 0.67 (95{\%} CI, 0.49-0.91; P = 0.01) comparing updated versus baseline cohort. A 12.4{\%} reduction inmedian duration of ICU stay (95{\%} CI, 0.5-22.8{\%}; P = 0.04) and a 14.0{\%} reduction in median duration of hospitalization (95{\%} CI, 2.0-24.5{\%}; P = 0.02) were also seen. No significant association with mortality (odds ratio, 1.18; 95{\%} CI, 0.80-1.76; P = 0.40) was seen. Conclusions: Implementation of an updated ICU analgesia, sedation, and delirium protocol was associated with an increase in RASS and CAM-ICU assessment and documentation; reduced hourly benzodiazepine dose; and decreased delirium and median durations of mechanical ventilation, ICU stay, and hospitalization.",
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author = "Dale, {Christopher R.} and Kannas, {Delores A.} and Fan, {Vincent S.} and Daniel, {Stephen L.} and Steven Deem and Norbert Yanez and Hough, {Catherine L.} and Dellit, {Timothy H.} and Miriam Treggiari",
year = "2014",
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T1 - Improved analgesia, sedation, and delirium protocol associated with decreased duration of delirium and mechanical ventilation

AU - Dale, Christopher R.

AU - Kannas, Delores A.

AU - Fan, Vincent S.

AU - Daniel, Stephen L.

AU - Deem, Steven

AU - Yanez, Norbert

AU - Hough, Catherine L.

AU - Dellit, Timothy H.

AU - Treggiari, Miriam

PY - 2014

Y1 - 2014

N2 - Rationale: Introduction of sedation protocols has been associated with improved patient outcomes. It is not known if an update to an existing high-quality sedation protocol, featuring increased patient assessment and reduced benzodiazepine exposure, is associated with improved patient process and outcome quality metrics. Methods: This was an observational before (n = 703) and after (n = 780) cohort study of mechanically ventilated patients in a 24-bed trauma-surgical intensive care unit (ICU) from 2009 to 2011. The three main protocol updates were: (1) requirement to document Richmond Agitation Sedation Scale (RASS) scores every 4 hours, (2) requirement to document Confusion Assessment Method-ICU (CAM ICU) twice daily, and ( 3 ) systematic, protocolized deescalation of excess sedation. Multivariable linear regression was used for the primary analysis. The primary outcome was the duration of mechanical ventilation. Prespecified secondary endpoints included days of delirium; the frequency of patient assessment with the RASS and CAM-ICU instruments; benzodiazepine dosing; durations of mechanical ventilation, ICU stay, and hospitalization; and hospital mortality and ventilator associated pneumonia rate. Results: Patients in the updated protocol cohort had 1.22 more RASS assessments per day (5.38 vs. 4.16; 95% confidence interval [CI], 1.05-1.39; P <0.01) and 1.15 more CAM-ICU assessments per day (1.49 vs. 0.35; 95% CI, 1.08-1.21; P <0.01) than the baseline cohort. The mean hourly benzodiazepine dose decreased by 34.8% (0.08 mg lorazepam equivalents/h; 0.15 vs. 0.23; P <0.01). In the multivariable model, the median duration of mechanical ventilation decreased by 17.6% (95% CI, 0.6-31.7%; P = 0.04). The overall odds ratio of delirium was 0.67 (95% CI, 0.49-0.91; P = 0.01) comparing updated versus baseline cohort. A 12.4% reduction inmedian duration of ICU stay (95% CI, 0.5-22.8%; P = 0.04) and a 14.0% reduction in median duration of hospitalization (95% CI, 2.0-24.5%; P = 0.02) were also seen. No significant association with mortality (odds ratio, 1.18; 95% CI, 0.80-1.76; P = 0.40) was seen. Conclusions: Implementation of an updated ICU analgesia, sedation, and delirium protocol was associated with an increase in RASS and CAM-ICU assessment and documentation; reduced hourly benzodiazepine dose; and decreased delirium and median durations of mechanical ventilation, ICU stay, and hospitalization.

AB - Rationale: Introduction of sedation protocols has been associated with improved patient outcomes. It is not known if an update to an existing high-quality sedation protocol, featuring increased patient assessment and reduced benzodiazepine exposure, is associated with improved patient process and outcome quality metrics. Methods: This was an observational before (n = 703) and after (n = 780) cohort study of mechanically ventilated patients in a 24-bed trauma-surgical intensive care unit (ICU) from 2009 to 2011. The three main protocol updates were: (1) requirement to document Richmond Agitation Sedation Scale (RASS) scores every 4 hours, (2) requirement to document Confusion Assessment Method-ICU (CAM ICU) twice daily, and ( 3 ) systematic, protocolized deescalation of excess sedation. Multivariable linear regression was used for the primary analysis. The primary outcome was the duration of mechanical ventilation. Prespecified secondary endpoints included days of delirium; the frequency of patient assessment with the RASS and CAM-ICU instruments; benzodiazepine dosing; durations of mechanical ventilation, ICU stay, and hospitalization; and hospital mortality and ventilator associated pneumonia rate. Results: Patients in the updated protocol cohort had 1.22 more RASS assessments per day (5.38 vs. 4.16; 95% confidence interval [CI], 1.05-1.39; P <0.01) and 1.15 more CAM-ICU assessments per day (1.49 vs. 0.35; 95% CI, 1.08-1.21; P <0.01) than the baseline cohort. The mean hourly benzodiazepine dose decreased by 34.8% (0.08 mg lorazepam equivalents/h; 0.15 vs. 0.23; P <0.01). In the multivariable model, the median duration of mechanical ventilation decreased by 17.6% (95% CI, 0.6-31.7%; P = 0.04). The overall odds ratio of delirium was 0.67 (95% CI, 0.49-0.91; P = 0.01) comparing updated versus baseline cohort. A 12.4% reduction inmedian duration of ICU stay (95% CI, 0.5-22.8%; P = 0.04) and a 14.0% reduction in median duration of hospitalization (95% CI, 2.0-24.5%; P = 0.02) were also seen. No significant association with mortality (odds ratio, 1.18; 95% CI, 0.80-1.76; P = 0.40) was seen. Conclusions: Implementation of an updated ICU analgesia, sedation, and delirium protocol was associated with an increase in RASS and CAM-ICU assessment and documentation; reduced hourly benzodiazepine dose; and decreased delirium and median durations of mechanical ventilation, ICU stay, and hospitalization.

KW - Critical care

KW - Delirium

KW - Protocol

KW - Quality improvement

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