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Reducing Deep Sedation and Delirium in Acute Lung Injury Patients: A Quality Improvement Project*

Hager, David N. MD, PhD1; Dinglas, Victor D. BS1,2; Subhas, Shilta RN3; Rowden, Annette M. Pharm D4; Neufeld, Karin J. MD, MPH2,5; Bienvenu, O. Joseph MD, PhD2,5; Touradji, Pegah PhD2,6; Colantuoni, Elizabeth PhD2,7; Reddy, Dereddi R.S. MD2,8; Brower, Roy G. MD1; Needham, Dale M. MD, PhD1,2,6

doi: 10.1097/CCM.0b013e31827ca949
Clinical Investigations

Objective: Deep sedation and delirium are common in the ICU. Mechanically ventilated patients with acute lung injury are at especially high risk for deep sedation, delirium, and associated long-term physical and neuropsychiatric impairments. We undertook an ICU-wide structured quality improvement project to decrease sedation and delirium.

Design: Prospective quality improvement project in comparison with a retrospective acute lung injury control group.

Setting: Sixteen-bed medical ICU in an academic teaching hospital with pre-existing use of goal-directed sedation with daily interruption of sedative infusions.

Patients: Consecutive acute lung injury patients.

Intervention: A “4Es” framework (engage, educate, execute, evaluate) was used as part of the quality improvement process. A new sedation protocol was created and implemented, which recommends a target Richmond Agitation Sedation Scale score of 0 (alert and calm) and requires failure of intermittent sedative dosing prior to starting continuous infusions. In addition, twice-daily delirium screening using the Confusion Assessment Method for the ICU was introduced into routine practice.

Measurements and Main Results: Sedative use and delirium status in acute lung injury patients after implementation of the quality improvement project (n = 82) were compared with a historical control group (n = 120). During the quality improvement vs. control periods, use of narcotic and benzodiazepine infusions were substantially lower (median proportion of medical ICU days per patient: 33% vs. 74%, and 22% vs. 70%, respectively, both p < 0.001). Further, wakefulness increased (median Richmond Agitation Sedation Scale score per patient: −1.5 vs. −4.0, p < 0.001), and days awake and not delirious increased (median proportion of medical ICU days per patient: 19% vs. 0%, p < 0.001).

Conclusion: Through a structured quality improvement process, use of sedative infusions can be substantially decreased and days awake without delirium significantly increased, even in severely ill, mechanically ventilated patients with acute lung injury.

1 Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.

2 Outcomes After Critical Illness and Surgery (OACIS) Research Group, Johns Hopkins University, Baltimore, MD.

3 Medical Intensive Care Unit, Johns Hopkins Hospital, Baltimore, MD.

4 Pharmacy, Johns Hopkins Hospital, Baltimore, MD.

5 Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, MD.

6 Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, MD.

7 Department of Biostatistics, Johns Hopkins University, Baltimore, MD.

8 Department of Medicine, Franklin Square Hospital Center, Baltimore, MD.

*See also p. 1573.

Drs. Dinglas and Needham received funding from the National Institutes of Health.

The remaining authors have disclosed that they do not have any potential conflicts of interest.

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© 2013 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins