Sedation and weaning from mechanical ventilation: effects of process optimization outside a clinical trial.
OBJECTIVE
We studied the effects of reorganization and changes in the care process, including use of protocols for sedation and weaning from mechanical ventilation, on the use of sedative and analgesic drugs and on length of respiratory support and stay in the intensive care unit (ICU).


METHODS
Three cohorts of 100 mechanically ventilated ICU patients, admitted in 1999 (baseline), 2000 (implementation I, after a change in ICU organization and in diagnostic and therapeutic approaches), and 2001 (implementation II, after introduction of protocols for weaning from mechanical ventilation and sedation), were studied retrospectively.


RESULTS
Simplified Acute Physiology Score II (SAPS II), diagnostic groups, and number of organ failures were similar in all groups. Data are reported as median (interquartile range). Time on mechanical ventilation decreased from 18 (7-41) (baseline) to 12 (7-27) hours (implementation II) (P = .046), an effect which was entirely attributable to noninvasive ventilation, and length of ICU stay decreased in survivors from 37 (21-71) to 25 (19-63) hours (P = .049). The amount of morphine (P = .001) and midazolam (P = .050) decreased, whereas the amount of propofol (P = .052) and fentanyl increased (P = .001). Total Therapeutic Intervention Scoring System-28 (TISS-28) per patient decreased from 137 (99-272) to 113 (87-256) points (P = .009). Intensive care unit mortality was 19% (baseline), 8% (implementation I), and 7% (implementation II) (P = .020).


CONCLUSIONS
Changes in organizational and care processes were associated with an altered pattern of sedative and analgesic drug prescription, a decrease in length of (noninvasive) respiratory support and length of stay in survivors, and decreases in resource use as measured by TISS-28 and mortality.
Jakob
Stephan M
SM
Department of Intensive Care Medicine, University Hospital Bern [Inselspital], CH-3010 Bern, Switzerland. stephan.jakob@insel.ch
Lubszky
Szabina
S
Friolet
Raymond
R
Rothen
Hans Ulrich
HU
Kolarova
Anna
A
Takala
Jukka
J
D018806:APACHE; D000368:Aged; D000465:Algorithms; D000700:Analgesics / Q000008:administration & dosage*; D002985:Clinical Protocols; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D006993:Hypnotics and Sedatives / Q000008:administration & dosage*; D007362:Intensive Care Units / Q000458:organization & administration*; D008297:Male; D008875:Middle Aged; D009936:Organizational Innovation; D017064:Process Assessment, Health Care; D012189:Retrospective Studies; D013557:Switzerland; D013997:Time Factors; D015300:Ventilator Weaning / Q000379:methods* / Q000706:statistics & numerical data
D000700:Analgesics; D006993:Hypnotics and Sedatives