title: Improved analgesia, sedation, and delirium protocol associated with decreased duration of delirium and mechanical ventilation.
abstract: BACKGROUND
  Introduction of sedation protocols has been associated with improved patient outcomes. It is not known if an update to an existing high-quality sedation protocol, featuring increased patient assessment and reduced benzodiazepine exposure, is associated with improved patient process and outcome quality metrics.
  
  
  METHODS
  This was an observational before (n = 703) and after (n = 780) cohort study of mechanically ventilated patients in a 24-bed trauma-surgical intensive care unit (ICU) from 2009 to 2011. The three main protocol updates were: (1) requirement to document Richmond Agitation Sedation Scale (RASS) scores every 4 hours, (2) requirement to document Confusion Assessment Method-ICU (CAM ICU) twice daily, and (3) systematic, protocolized deescalation of excess sedation. Multivariable linear regression was used for the primary analysis. The primary outcome was the duration of mechanical ventilation. Prespecified secondary endpoints included days of delirium; the frequency of patient assessment with the RASS and CAM-ICU instruments; benzodiazepine dosing; durations of mechanical ventilation, ICU stay, and hospitalization; and hospital mortality and ventilator associated pneumonia rate.
  
  
  RESULTS
  Patients in the updated protocol cohort had 1.22 more RASS assessments per day (5.38 vs. 4.16; 95% confidence interval [CI], 1.05-1.39; P < 0.01) and 1.15 more CAM-ICU assessments per day (1.49 vs. 0.35; 95% CI, 1.08-1.21; P < 0.01) than the baseline cohort. The mean hourly benzodiazepine dose decreased by 34.8% (0.08 mg lorazepam equivalents/h; 0.15 vs. 0.23; P < 0.01). In the multivariable model, the median duration of mechanical ventilation decreased by 17.6% (95% CI, 0.6-31.7%; P = 0.04). The overall odds ratio of delirium was 0.67 (95% CI, 0.49-0.91; P = 0.01) comparing updated versus baseline cohort. A 12.4% reduction in median duration of ICU stay (95% CI, 0.5-22.8%; P = 0.04) and a 14.0% reduction in median duration of hospitalization (95% CI, 2.0-24.5%; P = 0.02) were also seen. No significant association with mortality (odds ratio, 1.18; 95% CI, 0.80-1.76; P = 0.40) was seen.
  
  
  CONCLUSIONS
  Implementation of an updated ICU analgesia, sedation, and delirium protocol was associated with an increase in RASS and CAM-ICU assessment and documentation; reduced hourly benzodiazepine dose; and decreased delirium and median durations of mechanical ventilation, ICU stay, and hospitalization.
authors.affiliation: 1 Division of Pulmonary and Critical Care Medicine.
authors.forename: Christopher R
authors.initials: CR
authors.lastname: Dale
authors.forename: Delores A
authors.initials: DA
authors.lastname: Kannas
authors.forename: Vincent S
authors.initials: VS
authors.lastname: Fan
authors.forename: Stephen L
authors.initials: SL
authors.lastname: Daniel
authors.forename: Steven
authors.initials: S
authors.lastname: Deem
authors.forename: N David
authors.initials: ND
authors.lastname: Yanez
authors.forename: Catherine L
authors.initials: CL
authors.lastname: Hough
authors.forename: Timothy H
authors.initials: TH
authors.lastname: Dellit
authors.forename: Miriam M
authors.initials: MM
authors.lastname: Treggiari
mesh_terms: D000328:Adult; D000368:Aged; D000700:Analgesics / Q000008:administration & dosage*; D001569:Benzodiazepines / Q000008:administration & dosage; D002985:Clinical Protocols; D015331:Cohort Studies; D003422:Critical Care; D003693:Delirium / Q000517:prevention & control*; D004334:Drug Administration Schedule; D005260:Female; D006801:Humans; D006993:Hypnotics and Sedatives / Q000008:administration & dosage*; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care; D011595:Psychomotor Agitation / Q000517:prevention & control; D012121:Respiration, Artificial; D013997:Time Factors
chemical_list: D000700:Analgesics; D006993:Hypnotics and Sedatives; D001569:Benzodiazepines