(1284) Analgosedation Algorithm for Light Sedation in a Medical ICU

Introduction: The 2018 PADIS guidelines recommend using an assessment-driven, protocol-based, stepwise approach for pain and sedation management in critically ill adults. It was anecdotally noted at our institution that patients’ analgosedation was not titrated appropriately, resulting in patients remaining on unnecessarily high doses of analgosedatives for extended periods of time. As a result, an algorithm was created followed by a quality improvement project (QI) with the goal of increasing the percentage of fentanyl drips appropriately titrated to the Critical Care Pain Observation Tool (CPOT).

Methods: This QI project included intubated patients in a single-center 18-bed multisystem ICU on light sedation. Patients were excluded if they were being treated for alcohol withdrawal, status epilepticus, had a RASS goal from -3 to -5 or were on therapeutic hypothermia. This audit evaluated the appropriateness of fentanyl drip titrations to CPOT and sedative titrations to RASS in an 8-hour period. This audit was assessed by independent chart review, followed by immediate bedside discussion with nursing staff. ICU length of stay (LOS) and ventilator days were also retrospectively obtained. After the initial audit, corporate nursing education was provided followed by a post-intervention audit. Data collection was performed for four weeks before and after interventions.Data collection was performed for four weeks before and after interventions.

Results: Thirty-eight audits (21 patients) and 22 audits (20 patients) were completed pre- and post-interventions, respectively. In the pre-intervention group, 29% of fentanyl drips were appropriately titrated to CPOT, which was appropriate in 56% of cases during day shift and 16% during night shift. In the post-intervention group, 65% were appropriately titrated to CPOT: 67% during day shift and 63% during night shift. Mean ventilator days numerically decreased from 3.58 to 2.71 days and ICU LOS decreased from 8.75 to 6.93 days.

Conclusions: Appropriate fentanyl drip titration is challenging, particularly during night shift. Nursing education and use of a standardized titration protocol resulted in a two-fold increase in appropriate titration of analgosedation with decreased ventilator days and ICU LOS.