Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2011 Apr 8:3:21-7.
doi: 10.2147/OAEM.S17042. eCollection 2011.

Implementation of a guideline for the treatment of pain, sedation, agitation and neuromuscular blockade in the mechanically ventilated adult patient in the emergency department

Kristin E White  1 , Paul M Szumita  1 , Nicki Gilboy  2 , Hillary A Keenan  3 , Christian Arbelaez  2
Affiliations

Implementation of a guideline for the treatment of pain, sedation, agitation and neuromuscular blockade in the mechanically ventilated adult patient in the emergency department

Kristin E White et al. Open Access Emerg Med. .

Abstract

Purpose: When emergency department (ED) overcrowding includes admitted mechanically ventilated (MV) critically-ill patients without an open intensive care unit (ICU) bed, emergency providers must deliver ICU level care in the ED. Implementing standardized hospital based clinical guidelines may help providers achieve uniform care standards for assessing and managing pain and sedation for the MV patient.

Objective: This paper is a description of a hospital performance improvement project that was implemented in the ED. The objective of this study was to measure the degree of adoption of a hospital-wide clinical guideline for the management of pain, sedation and neuromuscular blockade in MV patients into clinical practice in the ED.

Methods: A retrospective analysis was performed for all mechanically ventilated patients who were admitted from ED to an Intensive Care Unit (ICU). Patient charts were reviewed before (December 2005) and after the implementation of the guideline (June, August, and December 2006). Data was collected and analyzed for the ED visit only and no ICU data was used. The primary outcome was the degree of adoption of the guideline by emergency providers into their daily clinical practice.

Results: A convenience sample of 170 adult MV patients who were admitted to the ICU during the preselected time period was analyzed. There were no demographic differences between groups of patients observed during each month interval, age (P = 0.34), gender (P = 0.40), race (P = 0.14), and Hispanic ethnicity (P = 0.84). Overall, there was an increase in the provider use of propofol (P < 0.01), RASS sedation scale (P < 0.01), and a decrease in the use of a paralytic agent (P < 0.01).

Conclusion: There was partial adoption of a guideline into their clinical practice by emergency providers in a busy urban emergency department. Across the 12-month implementation period, there was improvement in the assessment of and use of analgesia and sedation for MV patients.

Keywords: ICU; clinical guideline; critical care; emergency department; neuromuscular blocker; pain; sedation.

PubMed Disclaimer

Figures

Figure 1
Figure 1
Clinical algorithm for the hospital-wide guideline for the management of the mechanically vented adult patient. Abbreviations: *VAS, Visual Analog Scale; *RASS, Richmond Agitation and Sedation Scale; *BIS, Bispectral Index.
Figure 2
Figure 2
Study cohort after each implementation phase of the hospital-wide guideline for the management of the mechanically vented adult patient in the emergency department (December 2005 and December 2006).
See this image and copyright information in PMC

Similar articles

See all similar articles

References

    1. Gray A, Gill S, Airey M, Williams R. Descriptive epidemiology of adult critical care transfers from the emergency department. Emerg Med J. 2003;20(3):242–246. - PMC - PubMed
    1. Kress JP, Pohlman AS, O’Connor MF, Hall JB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med. 2000;342(20):1471–1477. - PubMed
    1. Wittbrodt ET. Daily interruption of continuous sedation. Pharmacotherapy. 2005;25(5 Pt 2):3S–7S. - PubMed
    1. Chalfin DB, Trzeciak S, Likourezos A, Baumann BM, Dellinger RP, DELAY-ED study group Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Crit Care Med. 2007;35(6):1477–1483. - PubMed
    1. Jacobi J, Fraser GL, Coursin DB, et al. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med. 2002;30(1):119–141. - PubMed