(1034) Make ‘Em Dream, Not Scream: Education and Order Changes Improve Post-Intubation Sedation Practices

Introduction: Awareness with paralysis (AWP) is an increasingly recognized problem in the Emergency Department (ED), with a reported incidence of around 2-3%. We proposed that education combined with an ED post-intubation quick order set will reduce the percentage of paralyzed patients not receiving appropriate sedation.

Methods: This was a pre-post interventional retrospective study of adults who received rocuronium within six hours of presenting to a large academic ED in Fresno, CA. The primary outcome was rates of post-intubation sedation compliance defined as receipt of fentanyl (≥ 75 mcg/hr with a ≥ 75 mcg bolus) with propofol (≥ 20 mcg/kg/min) or midazolam, (≥ 5 mg/hr with a ≥ 2 mg bolus) all within 15 minutes of receiving rocuronium. The primary interventions included education delivered by the study investigators via formal lectures and the creation of an ED post-intubation quick order set which reflected best sedation practices. The pre- and post-interventional study time periods were 1/1/23-4/30/23 and 1/1/24-4/30/24, respectively. A subgroup analysis was performed to compare the medical and surgical zones within the ED.

Results: 251 and 216 patients were included in the pre- and post-interventional groups, respectively. Appropriate post-intubation sedation was initiated in 0.8% and 15.7% of the pre and post-interventional groups, respectively (p < 0.001). Subgroup analysis revealed no statistically significant difference between the two zones during the pre-intervention period, but higher rates of compliance were observed in the medical zone during the post-intervention period (97% vs 3%, p < 0.001). In comparison to the pre-interventional group, significantly higher initial propofol and fentanyl infusion rates, lower midazolam usage, and a faster time to initiating propofol were observed in the post-interventional group.

Conclusions: Combining education with an ED post-intubation quick order set increased post-intubation sedation compliance rates.