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Effect of Best Practice Advisories on Sedation Protocol Compliance and Drug-Related Hazardous Condition Mitigation Among Critical Care Patients

Greene, Rebecca A. PharmD, BCCCP1; Zullo, Andrew R. PharmD, PhD1,2,3; Mailloux, Craig M. RN, BSN4; Berard-Collins, Christine RPh, MBA1; Levy, Mitchell M. MD, MCCM5; Amass, Timothy MD5

doi: 10.1097/CCM.0000000000004116
Clinical Investigation: PDF Only

Objectives: To determine whether best practice advisories improved sedation protocol compliance and could mitigate potential propofol-related hazardous conditions.

Design: Retrospective observational cohort study.

Setting: Two adult ICUs at two academic medical centers that share the same sedation protocol.

Patients: Adults 18 years old or older admitted to the ICU between January 1, 2016, and January 31, 2018, who received a continuous infusion of propofol.

Interventions: Two concurrent best practice advisories built in the electronic health record as a clinical decision support tool to enforce protocol compliance with triglyceride and lipase level monitoring and mitigate propofol-related hazardous conditions.

Measurements and Main Results: The primary outcomes were baseline and day 3 compliance with triglyceride and lipase laboratory monitoring per protocol and time to discontinuation of propofol in the setting of triglyceride and/or lipase levels exceeding protocol cutoffs. A total of 1,394 patients were included in the study cohort (n = 700 in the pre–best practice advisory group; n = 694 in the post–best practice advisory group). In inverse probability weighted regression analyses, implementing the best practice advisory was associated with a 56.6% (95% CI, 52.6–60.9) absolute increase and a 173% relative increase (risk ratio, 2.73; 95% CI, 2.45–3.04) in baseline laboratory monitoring. The best practice advisory was associated with a 34.0% (95% CI, 20.9–47.1) absolute increase and a 74% (95% CI, 1.39–2.19) relative increase in day 3 laboratory monitoring after inverse probability weighted analyses. Among patients with laboratory values exceeding protocol cutoffs, implementation of the best practice advisory resulted in providers discontinuing propofol an average of 16.6 hours (95% CI, 4.8–28.3) sooner than pre–best practice advisory. Findings from alternate analyses using interrupted time series were consistent with the inverse probability weighted analyses.

Conclusions: Best practice advisories can be effectively used in ICUs to improve sedation protocol compliance and may mitigate potential propofol-related hazardous conditions. Best practice advisories should undergo continuous quality assurance and optimizations to maximize clinical utility and minimize alert fatigue.

1Department of Pharmacy, Lifespan—Rhode Island Hospital, Providence, RI.

2Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI.

3Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI.

4Operational Excellence, Lifespan Corporate Services, Providence, RI.

5Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Rhode Island Hospital and Alpert Medical School of Brown University, Providence, RI.

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Dr. Zullo is supported by award 5K12HS022998 from the Agency for Healthcare Research and Quality. He is supported, in part, by a research grant from Sanofi Pasteur to Brown University on unrelated work that aims to understand the epidemiology of infections in long-term care facilities. He is also supported by a Department of Veterans Affairs Office of Academic Affiliations Advanced Fellowship in Health Services Research and Development. Dr. Amass’ institution received funding from National Institutes of Health (NIH), National Heart, Lung, and Blood Institute (grant number: T32HL134625), and the Brown University Respiratory Research Training Program, and he received support for article research from the NIH. The remaining authors have disclosed that they do not have any potential conflicts of interest.

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