DOES DAILY TRACKING IMPROVE CONCORDANCE?
Sedation and Analgesia Protocols in a Community-
Based Intensive Care Unit
Richard Nadeau, BMSc1
Robert J Anderson, MD FRCPC1,2
David Boyle, MD FRCPC1,2
1Northern Ontario School of Medicine2Hôpital régional de Sudbury Regional Hospital (HRSRH)
Department of Anaesthesia and Critical Care Medicine
Funding and Disclosure
Funding for this project provided by the Northern Ontario School of Medicine
Founding Dean Summer Medical StudentResearch Award (2009)
No conflicts of interest to disclose (all authors)
From Theory to Practice
Protocolized Sedation during MV
Brook et al, CCM 1998; 27 (12): 2609-15
Daily SAT
Kress et al, NEJM 2000; 342: 1471-7
Pairing SAT and SBT (ABC Trial)
Girard et al, Lancet 2008; 371: 126-34
Titrating to the Sedation Analgesia Scale
“A sedation goal or endpoint should be established and regularly redefined for each patient. Regular assessment and response to
therapy should be systematically documented.”(Grade of recommendation = C)
“The use of a validated sedation assessment scale (SAS, MAAS, or VICS) is recommended.”
(Grade of recommendation = B)
Jacobi et al. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. CCM 2002; 30 (1): 119-41
A Role for the Dedicated ICU Pharmacist?
Marshall et al, CCM 2008; 36 (2): 427-33
Study Design
Hypothesis: Having an auditor present to give daily feedback to the ICU Care Team will improve concordance to the protocol.
Setting: HRSRH Medical/Surgical ICUControl group: Retrospective chart reviewIntervention group: Daily audit and feedback of ICU
Care Team
Primary outcome measure: Concordance in proper utilization of the Protocol
Secondary outcome measures: Duration of mechanical ventilation (days) Amount of sedative administered
Propofol, BZD, opioids, ketamine and haloperidol
Concordance?
Protocol Ordered?
Yes No
Protocol Indicated?Yes
Concordant Discordant
NoDiscordant Concordant
IMPLEMENTED EACH STEP AS PER PROTOCOL?
YES NO
Concordant Discordant
Ordering the Protocol
n=149 n=72# ventilator days
Ordering and Implementing the Protocol
n=149
n=72
n=14
n=12
***p = 0.0002***p = 0.0002
# ventilator days
# concordant days
Implementing the Protocol
*p = 0.0163*p = 0.0163
n=95
n=51
# days Protocol ordered
Clinical Outcomes
Secondary Outcome Measure Control Intervention p value
Number of patients 32 23
Number of ventilator days 149 72
Ventilator duration (days), mean ± SD
4.14 ± 4.95 3.34 ± 2.81 0.4889
Propofol (mg/day), mean ± SD 2640.90 ± 2318.33 2294.40 ± 1530.11 0.2809
Lorazepam eq (mg/day), mean ± SD
14.82 ± 23.29 9.41 ± 9.76 0.2933
Fentanyl eq (mg/day), mean ± SD 542.53 ± 1092.64 576.35 ± 749.26 0.8637
Ventilator-associated pneumonia, n (%)
2 (5.56%) 1 (4.35%) 1.000
Venous thromboembolism, n (%) 1 (2.78%) 0 (0.00%) 1.000
Mortality, n (%) 9 (25.00%) 3 (13.04%) 0.3341
Conclusions and Discussion
Baseline concordance not very goodModest benefit of having auditor present
Improved ICU Care Team concordance when Protocol is ordered
Better sedative titration as per SAS
Is there a place for dedicated ICU pharmacist in a community-based ICU?
Limitations
Acknowledgments
Dr. Rob Anderson
All members of the ICU Care Team
Northern Ontario School of Medicine
QUESTIONS?QUESTIONS?