To determine the cost-effectiveness and safety of a set of rational use guidelines for analgesia, sedation, and neuromuscular blockade in critically ill ventilated patients when compared with similar factors in standard prescribing.
Prospective cost-benefit analysis.
Medical and surgical intensive care units (ICU) of a 350-bed tertiary care university hospital.
Patients admitted to our ICUs who required mechanical ventilation and continuous analgesics, sedatives, and/or neuromuscular junction blockers (NMJBs). There were 72 patients in the baseline and 84 patients in the follow-up groups.
Prospective tracking of eligible baseline patients was followed by the development and introduction of guidelines and an academic detailing process to promote the use of guidelines. Several months after the introduction of guidelines, a second group of eligible follow-up patients was tracked. The use and effectiveness of analgesics, sedatives, and NMJBs, as well as cost and outcomes, were followed in both groups. Data were subsequently reviewed and analyzed.
We recorded data by means of Paradox and Excel databases and included demographics, costs, outcomes (including adverse drug reactions, functional status, ventilator time in hours, lengths of stay), and mortality rates. Data were subsequently analyzed via the Winks statistical data analysis program. Both groups were similar with regard to demographics. There was a statistically significant increase in severity of illness in the follow-up group without a statistically significant increase in mortality. Direct drug costs, ventilator time, and lengths of stay were reduced in the follow-up group. In addition, the use of NMJBs was reduced from 30% in the baseline group to 5% in the follow-up group.
Rational use guidelines resulted in safe, cost-effective improvements in the provision of continuous analgesia, sedation, and neuromuscular blockade to critically ill patients requiring ventilator management when compared with similar factors in baseline prescribing strategies.
From the Departments of Anesthesiology (Drs. Mascia and Koch) and the Pharmacy Services, Division of Clinical Pharmacology (Dr. Medicis), State University of New York, Upstate Medical University, Syracuse, NY.
Supported, in part, by the Department of Anesthesiology, the Department of Pharmacy, and the Small Grants Projects of University Hospital through the Office of Clinical Practice Analysis, Upstate Medical University, Syracuse, NY.
Address requests for reprints to: Michael F. Mascia, MD, Tulane University School of Medicine, Department of Anesthesiology SL4, 1430 Tulane Avenue, New Orleans, LA 70112. E-mail: Masciam@aol.com