Tuesday, June 16, 2009 - Broward Health Leads South Florida in Sedation Best Practice Protocols

Broward General rolls out new protocols and systems beginning with nurse education on sedation/analgesia/delirium and neuromuscular blockage

Ft. Lauderdale, FL – Broward Health Broward General Medical Center’s new research-based sedation protocols will allow for more consistent patient monitoring and enhanced care.

The change in practice is in accordance with The Society of Critical Care Medicine’s (SCCM) (2002) clinical practice guidelines.  The guidelines are for the sustained use of analgesics and sedatives in maintaining optimal comfort for critically ill patients who suffer pain, anxiety and delirium.

Through collaboration among Broward General Medical Center ’s ICU committee, a need was identified for a protocol-driven policy and intervention plan.  This plan is focused upon best practice research to assist in the management of pain, sedation and the early detection and treatment of delirium.

Delirium presents serious implications for critically ill patients, and is an independent predictor of death with a three-fold greater risk of mortality. It is the most common mental disorder in ICUs and is experienced by 60 to 80 percent of mechanically ventilated patients. Delirium remains unrecognized in 66 to 84 percent of patients. The SCCM guidelines recommend that the emergence and/or persistence of delirium be regularly monitored in critically ill patients.

“For delirium, prevention is the key,” said Paul Brattan, RN, MS, clinical specialist in Broward General’s CCU/CVICU. “With best practice protocols and assessment scales in place, we can provide better patient care and improve outcomes, and that is our goal.”

Broward General’s program rollout involves education for all critical care nurses on sedation/analgesia/delirium and neuromuscular blockade therapy. The educational program will highlight recognizing the difference between the clinical subtypes of delirium (hypo and hyper), and the appropriate management. A focus to include non-pharmacological pain

interventions like noise reduction, environmental control and promoting REM sleep to avoid the onset of delirium will also be introduced as an adjunct to traditional methods of treatment.

The program will educate nurses to use the Confusion Assessment Method for the ICU (CAM-ICU) to routinely monitor patients for the presence delirium and the Richmond Agitation-Sedation Scale (RASS) to simultaneously assess the need for sedation. The Adult Non-Verbal Pain Scale (NVPS) has also been adopted as the formal pain scale to be utilized in assessing pain in mechanically ventilated patients.

Clear and concise communication between physician and nursing staff along with clear pre-set, protocol driven goals intended for the delivery of comfort and safety is the common thread for all. Clinical success will be achieved when mechanical ventilator times, intensive care unit stays, mortality and cases of delirium are decreased by minimizing drug accumulation and the long term affects they can cause.

“Through interdisciplinary collaboration between physicians, nurses and pharmacists a program has been developed that will benefit our patients,” said Gary Richmond, M.D. “The implementation of these best practice protocols and assessment scales is another step forward in providing the world-class care we all strive for.”

Acknowledgements to the following Broward General professionals for their contribution to this initiative: Mina Akhnoukh, M.D., department of anesthesia; Lisa Bergeron, RN, BSN, clinical specialist atrium ICU and respiratory care unit; Paul Brattan, RN, MS, clinical specialist CCU/CVICU; Joseph Catino, M.D., department of trauma services; Edward Czinn, M.D., chief of anesthesiology; Robert Cueli M.D., nephrology; Renee Greaves, PharmD; Sandeep Jain, M.D., department of pulmonology; Sunil Kumar, M.D., department of pulmonology; Elaine Miller, RN, BSN, nurse manager AICU; Gary Richmond, M.D., department of pulmonology; Edgar Rodas, M.D., department of trauma services; Alice Sparling, PharmD.

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