The effect of ICU sedation guidelines and pharmacist interventions on clinical outcomes and drug cost

Abstract

Objective: To measure the effect of evidence-based intensive care unit (ICU) sedation guidelines and interventions by a pharmacist to promote these guidelines on the weaning time from mechanical ventilation and sedation drug cost.

Design: Before-after study.

Setting: A 15-bed medical-surgical ICU at a tertiary-care teaching hospital.

Patients: 100 patients (2 groups of 50 consecutive patients) on mechanical ventilation (assist or pressure control mode for > or = 6 h) who were successfully discharged from the ICU.

Methods: ICU sedation guidelines were developed through physician, nursing, and pharmacy consensus using a physician survey and literature overview as points of reference and were implemented into practice. Prospectively, data on the time required to wean patients from mechanical ventilation (successful trial of T-piece, pressure support, or intermittent mandatory ventilation leading to extubation) and total drug costs for sedation were measured and compared between groups. All prospective ICU pharmacist interventions pertaining to sedation were documented.

Results: New sedation guidelines promoted lorazepam use in preference to midazolam and suggested propofol for patients not successfully sedated with high-dose lorazepam, haloperidol, or morphine. Over the 2-month collection periods, there was no difference in the median weaning time between the pre- (16 h, range 2-607) and post- (18 h, range 1-284) guideline groups. Total sedation drug costs decreased from $4515 to $1152 ($US) (p = 0.081). Median sedation drug costs decreased from $11.27 (range $0-1340) to $3.55 (range $0-250), with the amount (mg) of midazolam and propofol used decreasing by 86% and 100%, respectively. The ICU pharmacist successfully recommended a change from midazolam to lorazepam in 12 of 50 patients, 5 of whom had received midazolam for more than 24 hours.

Conclusions: High compliance with ICU sedation guidelines promoting lorazepam rather than midazolam or propofol in mechanically ventilated patients led to a 75% decrease in sedation drug costs and did not adversely affect the clinicians' ability to wean patients from mechanical ventilation.