title: Reducing deep sedation and delirium in acute lung injury patients: a quality improvement project.
abstract: 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.
  
  
  METHODS
  Prospective quality improvement project in comparison with a retrospective acute lung injury control group.
  
  
  METHODS
  Sixteen-bed medical ICU in an academic teaching hospital with pre-existing use of goal-directed sedation with daily interruption of sedative infusions.
  
  
  METHODS
  Consecutive acute lung injury patients.
  
  
  METHODS
  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.
  
  
  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).
  
  
  CONCLUSIONS
  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.
authors.affiliation: Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA. dhager1@jhmi.edu
authors.forename: David N
authors.initials: DN
authors.lastname: Hager
authors.forename: Victor D
authors.initials: VD
authors.lastname: Dinglas
authors.forename: Shilta
authors.initials: S
authors.lastname: Subhas
authors.forename: Annette M
authors.initials: AM
authors.lastname: Rowden
authors.forename: Karin J
authors.initials: KJ
authors.lastname: Neufeld
authors.forename: O Joseph
authors.initials: OJ
authors.lastname: Bienvenu
authors.forename: Pegah
authors.initials: P
authors.lastname: Touradji
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Colantuoni
authors.forename: Dereddi R S
authors.initials: DR
authors.lastname: Reddy
authors.forename: Roy G
authors.initials: RG
authors.lastname: Brower
authors.forename: Dale M
authors.initials: DM
authors.lastname: Needham
mesh_terms: D000046:Academic Medical Centers; D055371:Acute Lung Injury / Q000209:etiology / Q000628:therapy*; D000328:Adult; D015992:Body Mass Index; D002985:Clinical Protocols; D015897:Comorbidity; D054810:Deep Sedation / Q000379:methods*; D003693:Delirium / Q000175:diagnosis / Q000517:prevention & control*; D005260:Female; D006801:Humans; D007318:Inservice Training; D007362:Intensive Care Units / Q000458:organization & administration; D008297:Male; D008875:Middle Aged; D058996:Quality Improvement / Q000458:organization & administration*; D012121:Respiration, Artificial / Q000009:adverse effects / Q000379:methods*; D012959:Socioeconomic Factors