Minimizing Sedation with Enthusiasm!

Julie Rogan, MSN, CNS, ACCNS-AG, AOCNS

Penn Presbyterian Medical ICU

Philadelphia PA

My team!

Objectives

• Evaluate sedation practices in your ICU

• Formulate a plan to optimize sedative use in your ICU

• Demonstrate Interprofessional collaboration by redesigning structures in your ICU

EBP: ICU Liberation

• A-F Bundle

–Awake

–Breathing

–Choice of sedation

–Delirium

– Early and Progressive Mobility

– Family Engagement and Empowerment

Clinical Practice Guidelines

Crit Care Med 2013; 41: 263–306.

Pain in the ICU

• Causes of pain in the ICU

–Mechanical ventilation

– Immobility

– Foreign devices (IVs, catheters, ETT)

–Daily care (turning, PT/OT, oral care)

–Procedural pain

Pain in the ICU

• Pain in the ICU can have long term physiologic and psychologic effects

• Patients discharged from ICU, but still hospitalized

–82% remembered discomfort associated with ET tube

–77% experienced moderate to severe pain

Pain in the ICU

• Pain can present as agitation

– Treat pain first

–Pre-medicate before turns and repositioning

–Cluster care

– Explain to the patient what is going to happen

Pain in the ICU

• Optimize pain management to:

–Decrease sedative hypnotic use

–Decrease duration of mechanical ventilation, ICU LOS, etc.

• Utilize multimodal therapy when appropriate

Opioids

• Mechanism of Action

–Binds to opioid receptors in the CNS which inhibits pain signaling through the ascending pathways

• Also leads to sedation

• IV opioids used in the ICU

– Fentanyl

–Hydromorphone

–Morphine

Pharmacokinetic Comparison IV Opioid Onset

EliminationHalf-Life

Duration Active

Metabolite Miscellaneous

Fentanyl 1-2 min 2-4 hr 0.5-1 hr NoLess hemodynamiceffects compared to other opioids

Hydromorphone 5-15 min 2-3 hr 2-6 hr NoGood agent if tolerance builds to fentanyl or morphine

Morphine 5-10 min 3-4 hr 2-4hr Yes

Active metabolite is renally eliminated

Risk of histamine effects

Crit Care Med 2013; 41: 263–306.

Dosing ComparisonOpioid Starting Bolus

Intermittent Dosing

Starting Infusion

InfusionRange

Titration parameter

Fentanyl12.5-100mcg q10-15min

12.5-100mcg q1-2hr

12.5 mcg/hr

12.5-400 mcg/hr

Increase no more than 25mcg/hr q15 mins to target BPS,

NRS, RASS

Hydromorphone 0.4mg0.2-0.6mg q1-

2 hr0.5mg/hr

0.5-12 mg/hr

Increase no more than 0.5mg/hr q30 mins to target BPS,

NRS, RASS

Morphine 2-4mg2-4 mg q1-2 hr

0.5mg/hr0.5-12 mg/hr

Increase no more than 1mg/hr q15

mins to target BPS, NRS, RASS

Crit Care Med 2013; 41: 263–306.

Richmond Agitation and Sedation Scale

Score Term Description

+4 Combative Overly combative, violent, immediate danger to staff

+3 Very Agitated Pulls or removes tube(s) or catheter(s); aggressive

+2 Agitated Frequent non-purposeful movement, fights ventilator

+1 Restless Anxious, but movements not aggressive, vigorous

0 Alert and calm

-1 Drowsy Not fully alert, but has sustained awakening (eye-opening/eye contact) to voice

(> 10 seconds)

-2 Light sedation Briefly awakens with eye contact to voice

(< 10 seconds)

-3 Moderate sedation Movement or eye opening to voice

(but no eye contact)

-4 Deep sedation No response to voice, but movement or eye opening to physical stimulation

-5 Unarousable No response to voice or physical stimulation

Why do we routinely target -1 to 1?

• Deep sedation is associated with worse outcomes

– Increased duration of mechanical ventilation

– Increased ICU length of stay

– Increased risk of delirium development (benzodiazepines)

• Associated with long-term cognitive impairment

Crit Care Med 2013; 41: 263–306.Crit Care Med 2009; 37(9): 2527-2534

Why do we routinely target -1 to 1?

• Mental health following deep sedation

– Trouble remembering events of the ICU stay ( 37% vs. 14%; p=0.02)

–Disturbing memories of the ICU ( 18% vs 4%l p=0.05)

–Although not statistically significant, increase in PTSD symptoms

Crit Care Med 2013; 41: 263–306.Crit Care Med 2009; 37(9): 2527-2534

Sedation and Survival

Am J Respir Crit Care Med 2012; 186(8): 724-731.

Sedative Hypnotic Agents

• Propofol

–Mechanism of Action: Agonist at GABAA receptor and antagonist at NMDA receptor

–Adverse Effects: respiratory depressant, hypertriglyceridemia, hypotension, bradycarida, propofol-infusion syndrome

–No analgesic properties

Sedative Hypnotic Agents

• Dexmedetomidine (Precedex)

–Mechanism of Action: Selective alpha2 receptor agonist decreasing sympathetic output in the CNS

–Adverse Effects: bradycardia, hypotension, dependence with prolonged infusion

–Does not suppress respiratory drive

Sedative Hypnotic Agents

• Benzodiazepines (Midazolam, Lorazepam)

–Mechanism of Action: Agonist at GABAA receptor

–Adverse Effects: respiratory depressant, accumulation, delirium

–No analgesic properties

Pharmacokinetic Comparison

• Duration of effect is highly dependent on duration of infusion and lipophilicity (risk of tissue saturation)

Sedative-Hypnotic Onset Elimination

Half-Life Active Metabolite

Propofol 1-2 min3-12 hr

(increases with prolonged use)

No

Dexmedetomidine 5-10 min 1.8-3.1 hr No

Midazolam 3-5 min 3-11 hrYes (prolonged sedation with renal failure)

Lorazepam 15-20 min 8-15 hr No

Crit Care Med 2013; 41: 263–306.

Dosing Comparison Sedative-Hypnotic

Starting Bolus

Intermittent Dosing

Starting Infusion

InfusionRange

Titration parameter

PropofolDO NOT BOLUS

---- 5mcg/kg/min5-80

mcg/kg/min

Increase no more than 10 mcg/kg/min

q5 min to target RASS, BIS

DexmedetomidineDO NOT BOLUS

----0.2mcg/kg/hr 0.2-1.5

mcg/kg/hr

Increase no more than 0.1 mcg/kg/hrq30 min to target

RASS,

Midazolam1-2mg q10-15 mins

1-2mg q2-4 hr

0.5mg/hr0.5-15 mg/hr

Increase no more than 0.5 mg/hr q15 min to target RASS,

BIS

Lorazepam1-2mg q10-15mins

1-2mg q2-4 hr

0.5mg/hr0.5-10 mg/hr

Increase no more than 0.5 mg/hr q30 min to target RASS,

BIS

Crit Care Med 2013; 41: 263–306.

Sedation and Delirium

Anesthesiology 2006; 104(1): 21-6.

Spontaneous Awakening and Breathing

• Airway and Breathing Controlled Trial

– Study Design

• Multi-center, randomized controlled trial

–Patient Population

• N = 336 (168 patients per group)

– Intervention

• SATs paired with SBTs versus usual care plus a daily SBT

Lancet 2008; 371(9607):126-134.

Spontaneous Awakening and Breathing

• Airway and Breathing Controlled Trial

–Results

• Decreased days with ventilator support (14.7 days vs. 11.6 days; p=0.02)

• Decreased ICU and hospital discharge (9.1 days vs. 12.9 days; p=0.01 and 14.9 days versus 19.2 days; p=0.04, respectively

• Decreased mortality at 1 year ( HR 0.68; p=0.01, NNT = 7)

Lancet 2008; 371(9607):126-134.

Intermittent versus Continuous Sedation

Pros

• Immediate control over agitation

• Optimize pharmacologic principles of agents

• Reduced amount of continuous sedation required

Cons

• May not maintain baseline level of sedation

• More nursing time for administration (and witness waste)

*Balancing patient safety versus optimizing medication minimization (side effects)*

Intermittent versus Continuous Sedation

• What medications can be bolused?

• Fentanyl

• Hydromorphone

• Lorazepam

• Midazolam

• What medications can not be bolused?

• Propofol

• Dexmedetomidine

Bridging the gap . . .

I’m new here!

• One of 5 entities in health system

• 12-bed MICU

• 42 nurses

• 6 CNAs

• 8 hospitalists

What’s going on here?

• What I was told . . . We wait too long until traching

• What I was thinking . . . Why are patients intubated so long?

My observations

• Benzo drips

• No bolus sedation

• No RASS target ordered (0%)

• RASS and CAM inconsistently documented

• Sedation interruption/minimization not consistently addressed during rounds (less than 40%)

• Physical and occupational therapists trying to coordinate care

• Peanut Chews!

Barriers to changing sedation practices

•Patient is awake!• “We’re already doing this.”

• Level of comfort

• “What if my patient self-extubates?”

Unit Based Council Leadership

• Team meeting – Clinical Nurse Specialist – Nurse Manager – Medical Director – Lead Hospitalist – Physical and Occupational Therapists – Social Worker – Quality Improvement Advisor – Unit-Based Clinical Pharmacist– Respiratory Supervisor – Unit Council chairs– Infection Preventionist

• Review safety issues, HAI, staff concerns• Presentation of my observations with team discussion

Opportunities

• Median vent days 2.2 compared to 1.5 for rest of entity

• MICU Nursing and Quality Improvement were investigating data for trached patients

• Could we decrease time on vent to reduce need for trach?

Identified Gaps

• Team agreed our priority for 2017: Sedation Minimization

• Focus on RASS goals for all patients

• Target -1 to +1

• Create culture of sedation minimization

A3: Define the Problem

Intubated patients in the MICU at PPMC as of FY16 Q4 had median ventilator days of 2.2, compared to the UPHS median of 1.5 from the Philips eICU data. This puts PPMC MICU patients at risk for preventable hospital-acquired conditions. The MICU is uncertain about sustained compliance with ICU Liberation interventions, such as minimizing sedation. By December 2017, the PPMC MICU will reduce median ventilator days to 2.0, and improve compliance with SATs and with SBTs.

• Care delivery of the mechanically ventilated patient is of paramount importance in value-based critical care

• Processes are not in place to ensure delivery of evidence-based practices (spontaneous awakening and spontaneous breathing trials)

• The opportunity exists to shorten duration of mechanical ventilation and hospital length of stay by incorporating these processes into daily care

Goal Statement/Success Metrics

By December 2017, PPMC MICU will reduce duration of mechanical ventilation by 10% and achieve a target of 50% and 70%, respectively, for SAT and SBT compliance.

Business Impact

The ABCDEF bundle is an evidence-based approach to care for the mechanically ventilated patient that is endorsed by the Institute for Healthcare Improvement and evidence-based guidelines.

The benefit of this project will be reduction of HAC/HAI penalties

Reduction of medication costs?

Decreased time on mechanical ventilation?

Decreased cost of ICU care/length of stay?

Project Scope

In Scope: Mechanically ventilated patients (including patients receiving mechanical ventilation through tracheostomy)

• Start: = Medication administration

• Stop = patient off vent

• Out of Scope: Non-intubated patients and patients who do not qualify for PAD guidelines

Team

Executive Sponsor: Kevin Fosnocht

• Champion: Mark Mikkelsen

• Process Owner/Lead: Julie Rogan

• Mentor/Facilitator: Kelly Patton

• Team Members: Unit-based Clinical Pharmacist, Charge Nurse, Scott Egan, Diane Gorman, Huey Pigford

Problem/Opportunity Statement

Project Milestones

• Define Problem and Observe Process: December 2016-March 2017

• Measure Process: March 2017– Ongoing

• Get to the Root Cause: May 2017

• Identify Countermeasures and Pilot: June 2017

Project Charter Title: {PPMC MICU– Decreasing Vent Days by Embracing the ABCDEF Bundle}

Charter: Opportunity Statement

• Care delivery of the mechanically ventilated patient is of paramount importance in value-based critical care

•Processes are not in place to ensure delivery of evidence-based practices (spontaneous awakening and spontaneous breathing trials)

•The opportunity exists to shorten duration of mechanical ventilation and hospital length of stay by incorporating these processes into daily care

Charter: Business Impact

• The ABCDEF bundle is an evidence-based approach to care for the mechanically ventilated patient that is endorsed by the Institute for Healthcare Improvement and evidence-based guidelines.

• The benefit of this project will be reduction of HAC/HAI penalties

• Reduction of medication costs

• Decreased time on mechanical ventilation

• Decreased cost of ICU care/length of stay

Charter: Project Scope

•In Scope: Mechanically ventilated patients (including patients receiving mechanical ventilation through tracheostomy)

•Start: = Medication administration

•Stop = Patient off vent

• Out of Scope: Non-intubated patients and patients who do not qualify for PAD guidelines

Charter: Project Milestones

•Define Problem and Observe Process: December 2016-March 2017

•Measure Process: March 2017– Ongoing

•Get to the Root Cause: May 2017

•Identify Countermeasures and Pilot: June 2017

Charter: Success Metrics

• By December 2017, PPMC MICU will reduce duration of mechanical ventilation by 10% and achieve a target of 50% and 70%, respectively, for SAT and SBT compliance.

A3: Measure, Organize, and Clarify

• Start at intubation

• Look at medication administration

• Look for sedation interruptions

Data Collection• Red Cap

• Multiple revisions

• First looked at current conditions

A3: Analyze Root Cause

Data Collection Tool

• Every intubated patient

• First seven days of data per intubation

A3: Action Items

• Nurse Report Sheet

– Pain/Agitation/Delirium items moved to top

– Also used as guide for nurse presentation on patient-centered rounds

• Board Rounds

– Charge Nurse leads

– Utilizes structured sheet

Nurse Report Sheet and Rounds Presentation

Mobility Rounds Structure

• Daily at 8am

• Physical or Occupational Therapist, Clinical Nurse Specialist

• Walk to every room to visualize patient and communicate directly with clinical nurse– Coordinate sedation minimization to facilitate participation in therapy

– Prioritize therapy for patients who can participate

– Coordinate time for therapy around planned road trips and procedures

• Review presence or candidate for Healing Journal

• Daily review of necessity for restraints, IUC, central line

Board Rounds Structure

• Daily at 8:45am• Charge Nurse, Respiratory Therapist, Attending, Hospitalists• Review scheduled ICU road-trips, discharges, hospital census

– Prioritize and align rounding structure with discharges to floor

• Review mechanically ventilated patients for:– Sedative Minimization/Interruption

• Coordinate sedation minimization to facilitate ventilator liberation

– Spontaneous Breathing Trials (SBT)• Coordinate timely extubation for those who have passed SBT

– Delirium (CAM score)– Healing Journal

Charge Nurse Sheet for Board Rounds

Measurements Motivate: Leading Change

July 90.5%Spontaneous Awakening Trials

↓Duration of Mechanical Ventilation Improve Short- and Long-Term Outcomes

0

10

20

30

40

50

60

70

80

90

100

April May June July

Sedation Decreased

Sedation Off

A3: Plan for Sustainability

• Standard practice

• Continue to inform team about our metrics

• Tie in patient outcomes

• Present status of project at quarterly meetings to hospital leadership

Measures of Success

Median MV Duration

Change in Acuity

48

50

52

54

56

58

60

62

64

66

15Q4 16Q1 16Q2 16Q3 16Q4 17Q1 17Q2 17Q3

MICU Apache Scores

Operational Award Winner

PPMC MICU: Bringing Meaning and Life Back to Survivors of Critical Illness

ICU Diary

Reduce anxiety and post-traumatic

stress disorder in ICU survivors and

their loved ones through our healing

journal.

Embracing the ABCDEF Bundle

Achieving sedation minimization with

coordination of spontaneous breathing trials;

prevention, assessment , and management of

delirium; early and progressive mobility; family

engagement and empowerment.

Evaluation & Management of

recovery from critical illness

Contact survivors to enhance

understanding of ICU survivor

experience.

Survivorship

The power of post-traumatic

growth.

Care Coordination

Raise awareness of Post-

Intensive Care Syndrome

(PICS) during transitions in

care.

Community Outreach

Peer Support meetings for survivors

and their loved ones.

Resources

• www.pennmedicine.org/micu

• www.icudelirium.org

• www.deliriumnetwork.org

• www.nacns.org

• www.aacn.org

References

• Girard, TD., Kress, JP., Thomason, JW., Schweickert, WD., et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care. Lancet 2008; 371(9607):126-134.

• Pandharipande, P., Shintani, A., Peterson, J., et al. Lorazepam in an independent risk factor for transitioning to delirium in intensive care unit pateints. Anesthesiology 2006; 104(1): 21-6.

• Barr, J., Fraser, GL., Puntillo, K, Ely, EW., et al. Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit. Crit Care Med 2013; 41(1): 263–306.

• Shehabi, Y., Bellomo, R., Reade, MC., et al. Early Intensive Care Sedation Predicts Long-term Mortality in Ventilated Critically Ill Patients. Am J Respir Crit Care Med 2012; 186(8): 724-731.

• Treggiari, MM., Romand, J., Yanez, ND., et al. Randomized trial of light versus deep sedation on mental health after critical illness. Crit Care Med 2009; 37(9): 2527-2534