Evaluation of a clinical pathway for sedation and analgesia of mechanically ventilated patients in a cardiac intensive care unit (CICU): The Brigham and Women’s Hospital Levine CICU sedation pathways

Abstract

Background: Intravenous sedation and analgesia are important therapies during mechanical ventilation (MV). However, daily interruption of these medications is associated with improved outcomes in mechanically ventilated patients. We tested a clinical pathway for the use of sedation and analgesia during MV in a cardiac intensive care unit (CICU). Methods and results:We evaluated all mechanically ventilated patients in a CICU during two phases: phase 1 prior to pathway implementation (PRE) and phase 2 post-pathway implementation (POST). A total of 198 patients (98 PRE and 100 POST) and 1012 days of intubation (574 PRE and 434 POST) were included in this analysis. We found an increase in the frequency of daily interruptions of sedation post-implementation (49.3% PRE and 58.4% POST, p=0.0041). There was a significant decrease in the mean duration of MV in the POST vs PRE periods (5.0±2.3 vs 6.1±2.8 days, p=0.015). There was also a significant decrease in total neuroimaging studies (9 vs 49, p=0.001) and a trend toward a decrease in tracheostomies (3.0% vs 6.1% , p=0.33). Mean CICU length of stay (LOS) and hospital LOS respectively were 10.4 days and 16.8 days PRE and 10.4 days and 17.9 days POST (p=0.99 and p=0.55). Mortality did not differ (PRE 36.7% vs POST 32.0% p=0.55). Conclusions: Implementation of a pragmatic pathway for sedation and analgesia in a CICU was associated with an increase in the daily interruption of sedation and a corresponding decrease in the duration of MV days and the need for neuroimaging.

Mechanical ventilation and mobilization: comparison between genders

“…The present study showed that women who received early withdrawal of sedation also required shorter-duration MV. A similar finding was reported by Aday et al 15 ) , who observed a beneficial effect of sedation withdrawal on MV duration but not on length of stay in the ICU.…”

Editor’s Choice-Prospective registry of cardiac critical illness in a modern tertiary care Cardiac Intensive Care Unit

“…Consistent with expert recommendations, the CICU multidisciplinary team is engaged in quality improvement research within the CICU and collaboratively with other institutional leadership in critical care. 1,[7][8][9] The cardiovascular services at Brigham and Women's Hospital include a general cardiology service with an intermediate care unit with continuous telemetry and nursing care provided in a 1:3 or 1:4 nurse:patient ratio. Patients with acute coronary syndrome (ACS) are admitted to the intermediate care unit unless there are specific indications for critical care.…”

Struggling for a feasible tool – the process of implementing a clinical pathway in intensive care: a grounded theory study

“…The context of intensive care units (ICUs) is complex, as it includes critically ill patients and their relatives, sophisticated equipment, rapid advancement within medical and nursing care, and a large number of staff with different competences and attitudes who operate in teams with fluid membership [ 7 – 9 ]. The use of pathways in ICUs seems promising, as it can contribute to increased adherence to best-practice guidelines, streamlined care, a decreased mechanical ventilation time, and reduced complications [ 10 – 14 ]. As pathways are still rarely utilized in ICUs, further implementation has the potential to benefit both patients and healthcare providers [ 15 , 16 ].…”