(742) A Quality Improvement initiative in Reducing Variability in Sedation and Analgesia in a PICU

Introduction: Critically ill children require sedative and analgesia to mitigate effects of pain and anxiety and reduce metabolic demand and stress response.The 2022 Society of Critical Care Guidelines recommend using validated behavioral observation scales, such as the Richmond Agitation Sedation Scale (RASS) to adjust sedation levels in children. At our institution, no guideline existed to standardize provider titration practice so a Quality Improvement (QI) initiative was started with goal of reducing the mean cumulative dose of sedatives used in Pediatric Intensive Care Unit ( PICU)

Methods: Study is IRB-exempt.Inclusion criteria: Patients aged 1 month to 21 years admitted to PICU requiring intubation for acute respiratory failure secondary to respiratory diseases. Baseline data variables were collected from 12/ 01/2020, to 01/31/2023.Prospective data also included RASS score and the Withdrawal Assessment Tool (WAT-1) on patients during time period 03/ 01/2023 - 02/29,/2024. Primary outcome- reduction of mean cumulative dose of sedative by 20%. Secondary outcome measures:mean length of PICU stay and mean duration of mechanical ventilation days.Process measures include % of patients with RASS score goal documented, % of patients with a RASS score of -5 to -4 recorded in the nursing flow sheet prior to a paralytic medication ,% of withdrawal (WAT-1) scores documented in eligible patients. Balancing measure was rate of unplanned extubations

Results: When the rules of run charts were applied cumulative doses of propofol reduced by 45% and fentanyl by 9.5%. Duration on ventilator had a statistically meaningful reduction by 1.2 days.RASS scores documented in 91% of patients. For patients who received paralytics, RASS scores goal of -4 to -5 was achieved in 61% of patients. WAT-1 scores was documented in 93% of the charts. No increase in unplanned extubation during the first PDSA cycle

Conclusions: While propofol is the only sedative with the mean cumulative dose reduction by more than 20% overall recognition of over sedation, introduction of the new protocol has reduced variability between providers.It very is promising to see a meaningful reduction in the length of mechanical ventilation.Titrating of sedatives provided our nursing staff with autonomy resulting in patients receiving timely analgesia/sedation.