A Pediatric Sedation Protocol for Mechanically Ventilated Patients Requires Sustenance Beyond Implementation

Abstract

Objectives: To reevaluate the effect of a nursing-driven sedation protocol for mechanically ventilated patients on analgesic and sedative medication dosing durations. We hypothesized that lack of continued quality improvement efforts results in increased sedation exposure, as well as mechanical ventilation days, and ICU length of stay.

Design: Quasi-experimental, uncontrolled before-after study.

Setting: Forty-five-bed tertiary care, medical-surgical-cardiac PICU in a metropolitan university-affiliated children's hospital.

Patients: Children requiring mechanical ventilation longer than 48 hours not meeting exclusion criteria.

Interventions: During both the intervention and postintervention periods, analgesia and sedation were managed by nurses following an algorithm-based sedation protocol with a targeted comfort score.

Measurement and main results: The intervention cohort includes patients admitted during a 12-month period following initial protocol implementation in 2008-2009 (n = 166). The postintervention cohort includes patients meeting identical inclusion and exclusion criteria admitted during a 12-month period in 2012-2013 (n = 93). Median duration of total sedation days (IV plus enteral) was 5 days for the intervention period and 10 days for the postintervention period (p < 0.0001). The postintervention cohort received longer duration of mechanical ventilation (6 vs 5 d; p = 0.0026) and ICU length of stay (10 vs 8.5 d; p = 0.0543). After adjusting for illness severity and cardiac and surgical status, Cox proportional hazards regression analysis demonstrated that at any point in time, patients in the postintervention group were 58% more likely to be receiving sedation (hazard ratio, 1.58; p < 0.001) and 34% more likely to remain in the ICU (hazard ratio, 1.34; p = 0.019).

Conclusions: Sedation quality improvement measures related to the use of opiate infusions, total days of sedation exposure, PICU length of stay, and mechanical ventilation days all deteriorated following initial successful implementation of a PICU sedation protocol. Implementation of a protocol alone may not lead to sustained quality improvement without routine monitoring and ongoing education to ensure effectiveness.