DOES DAILY TRACKING IMPROVE CONCORDANCE? Sedation and Analgesia Protocols in a Community-Based Intensive Care Unit Richard Nadeau, BMSc 1 Robert J Anderson, MD FRCPC 1,2 David Boyle, MD FRCPC 1,2 1 Northern Ontario School of Medicine 2 Hôpital régional de Sudbury Regional Hospital (HRSRH) Department of Anaesthesia and Critical Care Medicine

Funding and Disclosure Funding for this project provided by the Northern Ontario School of Medicine Founding Dean Summer Medical Student Research Award (2009) No conflicts of interest to disclose (all authors)

From Theory to Practice

Protocolized Sedation during MV Brook et al, CCM 1998; 27 (12):

Daily SAT Kress et al, NEJM 2000; 342:

Pairing SAT and SBT (ABC Trial) Girard et al, Lancet 2008; 371:

Titrating to the Sedation Analgesia Scale “A sedation goal or endpoint should be established and regularly redefined for each patient. Regular assessment and response to therapy should be systematically documented.” (Grade of recommendation = C) “The use of a validated sedation assessment scale (SAS, MAAS, or VICS) is recommended.” (Grade of recommendation = B) Jacobi et al. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. CCM 2002; 30 (1):

A Role for the Dedicated ICU Pharmacist? Marshall et al, CCM 2008; 36 (2):

Study Design Hypothesis: Having an auditor present to give daily feedback to the ICU Care Team will improve concordance to the protocol. Setting: HRSRH Medical/Surgical ICU Control group: Retrospective chart review Intervention group: Daily audit and feedback of ICU Care Team Primary outcome measure:  Concordance in proper utilization of the Protocol Secondary outcome measures:  Duration of mechanical ventilation (days)  Amount of sedative administered  Propofol, BZD, opioids, ketamine and haloperidol

Concordance? Protocol Ordered? YesNo Protocol Indicated? Yes ConcordantDiscordant No DiscordantConcordant IMPLEMENTED EACH STEP AS PER PROTOCOL? YESNO ConcordantDiscordant

Ordering the Protocol n=149n=72# ventilator days

Ordering and Implementing the Protocol n=149n=72 n=14n=12 ***p = # ventilator days # concordant days

Implementing the Protocol *p = n=95n=51# days Protocol ordered

Clinical Outcomes Secondary Outcome MeasureControlInterventionp value Number of patients3223 Number of ventilator days14972 Ventilator duration (days), mean ± SD4.14 ± ± Propofol (mg/day), mean ± SD ± ± Lorazepam eq (mg/day), mean ± SD14.82 ± ± Fentanyl eq (mg/day), mean ± SD ± ± Ventilator-associated pneumonia, n (%)2 (5.56%)1 (4.35%)1.000 Venous thromboembolism, n (%)1 (2.78%)0 (0.00%)1.000 Mortality, n (%)9 (25.00%)3 (13.04%)0.3341

Conclusions and Discussion Baseline concordance not very good Modest benefit of having auditor present  Improved ICU Care Team concordance when Protocol is ordered  Better sedative titration as per SAS Is there a place for dedicated ICU pharmacist in a community-based ICU? Limitations

Acknowledgments Dr. Rob Anderson All members of the ICU Care Team Northern Ontario School of Medicine QUESTIONS?