Health Services ResearchA multicenter survey of Ontario intensive care unit nurses regarding the use of sedatives and analgesics for adults receiving mechanical ventilation☆
Introduction
Sedation and pain management are priority issues in the intensive care unit (ICU). Two randomized controlled trials [1], [2] and current clinical practice guidelines from a task force of the Society of Critical Care Medicine and the American Society of Health System Pharmacists [3] suggested that methods for administering sedation and analgesia can influence the morbidity and mortality associated with critical illness.
In a landmark trial, Brook et al [1] randomized 322 ICU patients receiving mechanical ventilation to standard care or to a nursing-implemented protocol for sedation and analgesia. In a related trial, Kress et al [2] examined the impact of daily interruption of sedative infusions among 128 critically ill adults. Both of these single-center studies incorporated a sedation scale and showed statistically significant reductions in the duration of mechanical ventilation and ICU length of stay of approximately 2 days. Subsequently, a standardized approach to sedation and analgesia that combines a protocol with a sedation/agitation scale is becoming more common in the care of patients receiving mechanical ventilation.
Traditionally, sedative and analgesic agents have been prescribed by physicians and administered by nurses, often with a wide margin of discretion in dose and without explicit understanding of the target level of sedation or analgesia. The satisfaction of ICU nurses with traditional drug prescribing and the impact of recent randomized trial results on nursing attitudes and practices are unclear.
The objectives of this survey of ICU nurses who were not using a standardized protocol or a sedation scale were to (1) understand nursing satisfaction with current sedation and analgesia practices as well as drug therapies in the ICU setting and the perceived relevance of protocolized sedation strategies to patient care and nursing autonomy and (2) identify areas for continuing education and clinical research.
Section snippets
Item generation and formatting
We generated items for the survey instrument through consultation with experts in critical care medicine (SM), pharmacy (LB), and nursing (PH). The 3-page questionnaire was formatted into 4 sections. Section 1 was a 1-page introduction to the topic that describes findings of the randomized trials by Brook et al [1] and Kress et al [2]. Section 2 consisted of 5 structured questions that elicit nursing satisfaction with current practice and the relevance of sedation protocols to patient care and
Results
In total, 88 critical care nurses completed the questionnaire (Mount Sinai Hospital, n = 38; St Joseph's Healthcare, n = 23; Hamilton Health Sciences General Hospital, n = 27). Thus, the percentage of nurses who completed the survey was 76% for Mount Sinai Hospital, was 30% for St Joseph's Healthcare, and was 28% for Hamilton Health Sciences General Hospital. Half of the respondents (52.7%) were either satisfied or extremely satisfied with the overall effectiveness of their respective ICU's
Discussion
In this survey of 88 nurses from 3 tertiary care medical-surgical ICUs in Ontario, we found that nearly half of the respondents were not satisfied with the current approach to sedation and analgesia in their institution. In addition, most nurses were dissatisfied with their level of autonomy in managing sedation and analgesia and believed that an approach combining a sedation protocol with a scale would be valuable to patient management and professional nursing practice. In general, the
Conclusions
There is now randomized trial evidence to suggest that strategies such as the use of nursing-driven sedation protocols, that of sedation scales, and daily interruption of sedation reduce the duration of mechanical ventilation and shorten length of stay among ICU patients. Although many ICUs have not yet implemented these strategies, their use in the clinical setting is expanding [9]. While designing a protocol for use in our ICU, we considered it essential to understand nurses' perspectives on
References (9)
- et al.
Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation
Crit Care Med
(1999) - et al.
Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation
N Engl J Med
(2000) Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult
Crit Care Med
(2002)A sharper Bonferroni procedure for multiple significance testing
Biometrika
(1988)
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Authors' contributions: SM, PH, and LB conceived of the study and participated in its design and coordination. MOM, DJC, and EM coordinated the study at their respective institutions and participated in manuscript preparation. WF performed the data entry and drafted the manuscript. DH performed the statistical analysis. All authors read and approved the final manuscript.