Evaluation of physician and nursing adherence to a sedation and analgesia protocol in mechanically ventilated patients

Introduction: Implementation of goal-directed sedation and analgesia in the intensive care unit (ICU) has shown to improve outcomes in mechanically ventilated patients. The protocol at our institution was recently revised and titration guidelines were incorporated to provide standardized care.

Objectives: The objective of this study was to evaluate appropriate physician prescribing and nursing titration of sedatives and analgesics per protocol in mechanically ventilated ICU patients.

Study Design: This was a single center, retrospective study conducted between March to September 2015, which received Institutional Review Board approval.

Methods: Information was collected utilizing electronic health records for fifty protocol orders initiated within the study time frame. The following data was collected and analyzed: goal Critical Care Pain Observation Tool (CPOT) score, goal Richmond Agitation Sedation Scale (RASS) score, bolus dose, starting, titration, and maximum rates of infusion. Prescriber adherence was measured by the percent of protocol orders completed correctly. Nursing adherence was measured by percentage of orders with documented RASS and CPOT scores, subsequent titration of medications and completion of daily awakenings per protocol.

Results: Data from 50 protocol orders were included. Most commonly prescribed medication regimens were combinations of analgesics and sedatives (n=41). Appropriate completion of orders by prescribers was found to be 88%. The most commonly omitted component was the bolus dosing regimen. Nursing adherence rate was higher for RASS score documentation than CPOT scores (77 percent versus 55 percent, respectively). Approximately 40 percent of medication titrations were not completed per protocol. Sixty percent of these inappropriate titrations were due to deviation from the prescribed starting rate. Nursing documentation for daily awakenings was performed per protocol for 40 percent of 198 patient days. 

Conclusions: The study identified deviations from the protocol, which warrant further evaluation and reeducation to improve adherence.