Deborah Frank, MD, PhD
UVA Childrens Hospital
Salt Lake City, UT
Disclosure information not submitted.
Jennifer Kragie, BSN, CCRN, CPN, AC-APRN
Clinician VI, PICU
UVA Children's
Charlottesville, Virginia, United States
Disclosure information not submitted.
Nicole Frank, PA
Physician's Assistant
UVA Children's
Charlottesville, Virginia, United States
Disclosure information not submitted.
Melissa Sacco, MD, MS
Associate Professor of Pediatrics
UVA Children's
Charlottesville, Virginia, United States
Disclosure information not submitted.
Kelly Lunsford, PharmD, BCPPS
Pediatric Pharmacist
UVA Children's
Charlottesville, Virginia, United States
Disclosure information not submitted.
Title: Refining sedation practices in a Pediatric ICU requires sustained effort
Introduction: Maintaining safety and comfort for PICU patients is challenging. Achieving appropriate sedation without causing delirium or withdrawal is the goal. In our 17-bed PICU, we implemented sequential sedation quality improvement initiatives from 2017-2020. We tracked aggregate midazolam and morphine bolus doses per patient as our metric.
Methods: Our QI team put into practice 3 assessment tools and 4 evidence-based guidelines to help standardize communication and practice, while allowing flexibility for individual patients. Tools were brought into practice through 2017. Delirium, iatrogenic withdrawal, and mobility guidelines were implemented in late 2018 and a sedation guideline in late 2019. Date of bolus doses of morphine and midazolam were abstracted from our pharmacy database and analyzed by patient, month and year. Monthly data was visualized as a run chart. Yearly data was analyzed using Kruskal-Wallis tests with comparisons made to 2016 pre-intervention data.
Results: The linear trend lines for the 60-month (beginning 1-2016) run chart for midazolam and morphine bolus doses have equations of y = -0.002x + 95 and y=-0.001 +59, respectively, where y is the median per patient bolus doses given and x is the month. The midazolam trend line has a more negative slope than morphine. Yearly midazolam and morphine median per patient doses decreased from 2016 through 2018, then increased. For midazolam, 5 doses/pt in 2019 was decreased from 8.5 in 2016 (p= -0.004). For morphine, 9 doses/pt in 2018 was decreased from 15 doses/pt in 2016 (p=0.001).
Conclusions: Prior to 2017, our primary sedatives were midazolam and morphine. With our early delirium interventions, benzodiazepines were discouraged, and we shifted to a dexmedetomidine and morphine sedation strategy. With our QI efforts, midazolam and morphine boluses decreased from 2016 to 2018-2019; however, these decreases were not sustained through 2020. Initial success in changing our sedation culture took focused effort. Sedation practices are complex as are the reasons for the lack of sustainability. We suspect QI team and PICU staff turnover, increasing PICU census and acuity, and the COVID pandemic all contributed. Additionally, measuring culture change is challenging, and it is unclear if median bolus doses per patient is the best metric.