Evaluation of a minimal sedation protocol using ICU sedative consumption as a monitoring tool: a quality improvement multicenter project
Identifieur interne : 000159 ( Main/Exploration ); précédent : 000158; suivant : 000160Evaluation of a minimal sedation protocol using ICU sedative consumption as a monitoring tool: a quality improvement multicenter project
Auteurs : Otavio T. Ranzani [Brésil] ; Evelyn Senna Simpson [Brésil] ; Talita Barbosa Augusto [Brésil] ; Sylas Bezerra Cappi [Brésil] ; Danilo Teixeira Noritomi [Brésil]Source :
- Critical Care [ 1364-8535 ] ; 2014.
Abstract
Oversedation frequently occurs in ICUs. We aimed to evaluate a minimal sedation policy, using sedative consumption as a monitoring tool, in a network of ICUs targeting decrement of oversedation and mechanical ventilation (MV) duration.
A prospective quality improvement project was conducted in ten ICUs within a network of nonteaching hospitals in Brazil during a 2-year period (2010 to 2012). In the first 12 months (the preintervention period), we conducted an audit to identify sedation practice and barriers to current guideline-based practice regarding sedation. In the postintervention period, we implemented a multifaceted program, including multidisciplinary daily rounds, and monthly audits focusing on sedative consumption, feedback and benchmarking purposes. To analyze the effect of the campaign, we fit an interrupted time series (ITS). To account for variability among the network ICUs, we fit a hierarchical model.
During the study period, 21% of patients received MV (4,851/22,963). In the postintervention period, the length of MV was lower (3.91 ± 6.2 days versus 3.15 ± 4.6 days; mean difference, −0.76 (95% CI, −1.10; −0.43),
By using a light sedation policy in a group of nonteaching hospitals, we reproduced the benefits that have previously been demonstrated in controlled settings. Furthermore, systematic monitoring of sedative consumption should be a feasible instrument for supporting the implementation of a protocol on a large scale.
The online version of this article (doi:10.1186/s13054-014-0580-3) contains supplementary material, which is available to authorized users.
Url:
DOI: 10.1186/s13054-014-0580-3
PubMed: 25673553
PubMed Central: 4234844
Affiliations:
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Ranzani</name><affiliation wicri:level="3"><nlm:aff id="Aff1">Critical Care Department, Hospital Paulistano, Rua Martiniano de Carvalho, 741, São Paulo, 01321-001 Brazil</nlm:aff><country xml:lang="fr">Brésil</country><wicri:regionArea>Critical Care Department, Hospital Paulistano, Rua Martiniano de Carvalho, 741, São Paulo</wicri:regionArea><placeName><settlement type="city">São Paulo</settlement><region type="state">État de São Paulo</region></placeName></affiliation><affiliation wicri:level="4"><nlm:aff id="Aff2">Respiratory Intensive Care Unit, Pulmonary Division, Heart Institute, Hospital das Clínicas, University of São Paulo, Rua Enéas Carvalho de Aguiar, 255, sala 6040, 6° andar, São Paulo, 05403-000 Brazil</nlm:aff><country xml:lang="fr">Brésil</country><wicri:regionArea>Respiratory Intensive Care Unit, Pulmonary Division, Heart Institute, Hospital das Clínicas, University of São Paulo, Rua Enéas Carvalho de Aguiar, 255, sala 6040, 6° andar, São Paulo</wicri:regionArea><placeName><settlement type="city">São Paulo</settlement><region type="state">État de São Paulo</region></placeName><orgName type="university">Université de São Paulo</orgName></affiliation></author><author><name sortKey="Simpson, Evelyn Senna" sort="Simpson, Evelyn Senna" uniqKey="Simpson E" first="Evelyn Senna" last="Simpson">Evelyn Senna Simpson</name><affiliation wicri:level="3"><nlm:aff id="Aff1">Critical Care Department, Hospital Paulistano, Rua Martiniano de Carvalho, 741, São Paulo, 01321-001 Brazil</nlm:aff><country xml:lang="fr">Brésil</country><wicri:regionArea>Critical Care Department, Hospital Paulistano, Rua Martiniano de Carvalho, 741, São Paulo</wicri:regionArea><placeName><settlement type="city">São Paulo</settlement><region type="state">État de São Paulo</region></placeName></affiliation></author><author><name sortKey="Augusto, Talita Barbosa" sort="Augusto, Talita Barbosa" uniqKey="Augusto T" first="Talita Barbosa" last="Augusto">Talita Barbosa Augusto</name><affiliation wicri:level="3"><nlm:aff id="Aff1">Critical Care Department, Hospital Paulistano, Rua Martiniano de Carvalho, 741, São Paulo, 01321-001 Brazil</nlm:aff><country xml:lang="fr">Brésil</country><wicri:regionArea>Critical Care Department, Hospital Paulistano, Rua Martiniano de Carvalho, 741, São Paulo</wicri:regionArea><placeName><settlement type="city">São Paulo</settlement><region type="state">État de São Paulo</region></placeName></affiliation></author><author><name sortKey="Cappi, Sylas Bezerra" sort="Cappi, Sylas Bezerra" uniqKey="Cappi S" first="Sylas Bezerra" last="Cappi">Sylas Bezerra Cappi</name><affiliation wicri:level="3"><nlm:aff id="Aff1">Critical Care Department, Hospital Paulistano, Rua Martiniano de Carvalho, 741, São Paulo, 01321-001 Brazil</nlm:aff><country xml:lang="fr">Brésil</country><wicri:regionArea>Critical Care Department, Hospital Paulistano, Rua Martiniano de Carvalho, 741, São Paulo</wicri:regionArea><placeName><settlement type="city">São Paulo</settlement><region type="state">État de São Paulo</region></placeName></affiliation></author><author><name sortKey="Noritomi, Danilo Teixeira" sort="Noritomi, Danilo Teixeira" uniqKey="Noritomi D" first="Danilo Teixeira" last="Noritomi">Danilo Teixeira Noritomi</name><affiliation wicri:level="3"><nlm:aff id="Aff1">Critical Care Department, Hospital Paulistano, Rua Martiniano de Carvalho, 741, São Paulo, 01321-001 Brazil</nlm:aff><country xml:lang="fr">Brésil</country><wicri:regionArea>Critical Care Department, Hospital Paulistano, Rua Martiniano de Carvalho, 741, São Paulo</wicri:regionArea><placeName><settlement type="city">São Paulo</settlement><region type="state">État de São Paulo</region></placeName></affiliation></author></analytic><series><title level="j">Critical Care</title><idno type="ISSN">1364-8535</idno><idno type="e-ISSN">1466-609X</idno><imprint><date when="2014">2014</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec><title>Introduction</title><p>Oversedation frequently occurs in ICUs. We aimed to evaluate a minimal sedation policy, using sedative consumption as a monitoring tool, in a network of ICUs targeting decrement of oversedation and mechanical ventilation (MV) duration.</p></sec><sec><title>Methods</title><p>A prospective quality improvement project was conducted in ten ICUs within a network of nonteaching hospitals in Brazil during a 2-year period (2010 to 2012). In the first 12 months (the preintervention period), we conducted an audit to identify sedation practice and barriers to current guideline-based practice regarding sedation. In the postintervention period, we implemented a multifaceted program, including multidisciplinary daily rounds, and monthly audits focusing on sedative consumption, feedback and benchmarking purposes. To analyze the effect of the campaign, we fit an interrupted time series (ITS). To account for variability among the network ICUs, we fit a hierarchical model.</p></sec><sec><title>Results</title><p>During the study period, 21% of patients received MV (4,851/22,963). In the postintervention period, the length of MV was lower (3.91 ± 6.2 days versus 3.15 ± 4.6 days; mean difference, −0.76 (95% CI, −1.10; −0.43), <italic>P</italic> <0.001) and 28 ventilator-free days were higher (16.07 ± 12.2 days versus 18.33 ± 11.6 days; mean difference, 2.30 (95% CI, 1.57; 3.00), <italic>P</italic> <0.001) than in the preintervention period. Midazolam consumption (in milligrams per day of MV) decreased from 329 ± 70 mg/day to 163 ± 115 mg/day (mean difference, −167 (95% CI, −246; −87), <italic>P</italic> <0.001). In contrast, consumption of propofol (<italic>P</italic> = 0.007), dexmedetomidine (<italic>P</italic> = 0.017) and haloperidol (<italic>P</italic> = 0.002) increased in the postintervention period, without changes in the consumption of fentanyl. Through ITS, age (<italic>P</italic> = 0.574) and Simplified Acute Physiology Score III (<italic>P</italic> = 0.176) remained stable. The length of MV showed a secular effect (secular trend β<sub>1</sub> = −0.055, <italic>P</italic> = 0.012) and a strong decrease immediately after the intervention (intervention β<sub>2</sub> = −0.976, <italic>P</italic> <0.001). The impact was maintained over the course of one year, despite the waning trend for the intervention’s effect (postintervention trend β<sub>3</sub> = 0.039, <italic>P</italic> = 0.095).</p></sec><sec><title>Conclusions</title><p>By using a light sedation policy in a group of nonteaching hospitals, we reproduced the benefits that have previously been demonstrated in controlled settings. Furthermore, systematic monitoring of sedative consumption should be a feasible instrument for supporting the implementation of a protocol on a large scale.</p></sec><sec><title>Electronic supplementary material</title><p>The online version of this article (doi:10.1186/s13054-014-0580-3) contains supplementary material, which is available to authorized users.</p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Barr, J" uniqKey="Barr J">J Barr</name></author><author><name sortKey="Fraser, Gl" uniqKey="Fraser G">GL Fraser</name></author><author><name sortKey="Puntillo, K" uniqKey="Puntillo K">K Puntillo</name></author><author><name sortKey="Ely, Ew" uniqKey="Ely E">EW Ely</name></author><author><name sortKey="Gelinas, C" uniqKey="Gelinas C">C Gélinas</name></author><author><name sortKey="Dasta, Jf" uniqKey="Dasta J">JF Dasta</name></author><author><name sortKey="Davidson, Je" uniqKey="Davidson J">JE 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uniqKey="Fan V">VS Fan</name></author><author><name sortKey="Daniel, Sl" uniqKey="Daniel S">SL Daniel</name></author><author><name sortKey="Deem, S" uniqKey="Deem S">S Deem</name></author><author><name sortKey="Yanez, Nd" uniqKey="Yanez N">ND Yanez</name></author><author><name sortKey="Hough, Cl" uniqKey="Hough C">CL Hough</name></author><author><name sortKey="Dellit, Th" uniqKey="Dellit T">TH Dellit</name></author><author><name sortKey="Treggiari, Mm" uniqKey="Treggiari M">MM Treggiari</name></author></analytic></biblStruct></listBibl></div1></back></TEI><affiliations><list><country><li>Brésil</li></country><region><li>État de São Paulo</li></region><settlement><li>São Paulo</li></settlement><orgName><li>Université de São Paulo</li></orgName></list><tree><country name="Brésil"><region name="État de São Paulo"><name sortKey="Ranzani, Otavio T" sort="Ranzani, Otavio T" uniqKey="Ranzani O" first="Otavio T" last="Ranzani">Otavio T. Ranzani</name></region><name sortKey="Augusto, Talita Barbosa" sort="Augusto, Talita Barbosa" uniqKey="Augusto T" first="Talita Barbosa" last="Augusto">Talita Barbosa Augusto</name><name sortKey="Cappi, Sylas Bezerra" sort="Cappi, Sylas Bezerra" uniqKey="Cappi S" first="Sylas Bezerra" last="Cappi">Sylas Bezerra Cappi</name><name sortKey="Noritomi, Danilo Teixeira" sort="Noritomi, Danilo Teixeira" uniqKey="Noritomi D" first="Danilo Teixeira" last="Noritomi">Danilo Teixeira Noritomi</name><name sortKey="Ranzani, Otavio T" sort="Ranzani, Otavio T" uniqKey="Ranzani O" first="Otavio T" last="Ranzani">Otavio T. Ranzani</name><name sortKey="Simpson, Evelyn Senna" sort="Simpson, Evelyn Senna" uniqKey="Simpson E" first="Evelyn Senna" last="Simpson">Evelyn Senna Simpson</name></country></tree></affiliations></record>Pour manipuler ce document sous Unix (Dilib)
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