The Impact of Sedation Protocols on Cost of Care: A Systematic Review
CCCF ePoster library. Young A. Nov 2, 2016; 150975; 94
Dr. Amanda Young
Dr. Amanda Young
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Topic: Systematic Review, Meta-analysis, or Meta-synthesis

The Impact of Sedation Protocols on Cost of Care: A Systematic Review

Amanda Young, MD1; Erin Rosenberg, MD, FRCPC2; Gianni D’Egidio, MD, FRCPC2; Kwadwo Kyeremanteng, MD, FRCPC2.
1University of Ottawa, Ottawa, Canada; 2Department of Critical Care Medicine, The Ottawa Hospital, Ottawa, Canada.


Introduction: Sedation is used in the care of the majority of mechanically ventilated patients in an intensive care unit. Sedation may be protocolized, which may or may not include daily interruptions of sedation. Previous studies have shown that the use of sedation protocols are associated with improvement in outcomes such as decreased ICU and hospital LOS, duration of mechanical ventilation, mortality, delirium, and costs.
Objective: We hypothesized that the use of sedation protocols would decrease the total cost of care in hospital for mechanically ventilated patients compared to the use of sedation without protocols, guidelines or daily interruptions.
Methods: We searched the PubMed, Cochrane, and Embase databases for articles from the year 2000 to present. The titles of all studies were read and screened by four independent physicians to remove all non-applicable studies. Abstracts were then reviewed to determine if they should potentially be included. The selected publications were then read entirely. We used the Effective Public Health Practice Project (EPHPP) assessment tool to assess the quality of the studies included in the review.
Results: 866 titles were obtained in the initial search. 60 articles were thought to be potentially applicable to our review after reading the titles and abstracts. These 60 studies were read in full. 18 studies were included after reading the full articles. Five studies were included in the final review process after four physicians reviewed all 18 studies. We did not include articles where the effect of multiple interventions on cost was considered, due to the inability to then isolate the effect that sedation protocols had on cost. Quintard, et. al. showed that the cost of sedation per ventilated patient was €145 vs €93 after the implementation of a sedation protocol. They also showed a net savings of €27,360 in total or €80/patient between the two respective years of observation (pre vs. post-intervention) due to decrease in number of mechanical ventilation days. Awissi, et. al. showed that mean total cost of sedation per patient per hospitalization was $59.97 vs. $46.02 (p=0.01) after the implementation of a sedation protocol. Barbarello-Andrews, et. al. showed a projected annualized reduction in cost of  $2.23 million between the 2 campuses studied due to reduction in ICU LOS, and an actual reduction in cost of $379,500 due to reduction in number of cases of VAP with implementation of sedation protocols over 5 months. Prat, et. al. showed that cost of sedation per year was €171,314/yr vs. €35,629/yr after sedation protocol implementation in their centre. Adam et. al. showed that cost of sedative agents was £6285 vs. £3629 per month (p < 0.0001) after implementation of a sedation protocol.
Conclusions: This systematic review shows a statistically significant reduction in cost of care with implementation of sedation protocols. We cannot draw definitive conclusions from this study due to overall weak evidence. The reduction in cost may be related to decrease in ICU LOS, decease in cost of sedative agents or other factors. Further (preferably RCT) studies are needed to determine definitively whether sedation protocols reduce cost of care, and what the sedation protocols must include to have this effect. Further studies would also be useful to determine what drives reduction in cost of care (ie. Decreased ICU LOS vs. decreased drug costs, etc).



[1] Article in Press: Rose L, et al, Clinician perspectives on protocols designed to minimize sedation. J Crit Care (2014), 10.1016/j.jcrc.2014.10.021
[2] Jackson, D. L., et. al. (2010). A Systematic Review of the Impact of Sedation Practice in the ICU on Resource Use, Costs, and Patient Safety. Critical Care, 14:R59.
[3] Hughes, C. G., et. al. (2012). Sedation in the intensive care setting. Clin. Pharmacol. 4, 53-63.
[4] Quintard, H., et al. (2012). Impact clinique et économique d’une politique de contrôle de la sédation par protocole dans un service de réanimation médicochirurgicale. Annales Françaises d’Anesthésie et de Réanimation. 31, 778–782.
[5] Awissi, D.-K., et. al. (2012). I-SAVE Study: Impact of Sedation, Analgesia, and Delirium Protocols Evaluated in the Intensive Care Unit: An Economic Evaluation. Ann. Pharmacother. 46, 21-28.
[6] Barbarello-Andrews, L., et. al. Cost-Effective Medication Use in Critical Care: Capital Health System’s Experience in VHA’s MUSIC Program. JCOM. 13(11), 615-622.
[7] Prat, G., et. al. (2009). Durability and efficiency over time of a nurse-driven sedation and analgesia protocol in a medical ICU.
[8] Adam, C., et. al. (2006). Impact of introducing a sedation management guideline in intensive care. Anaesthesia. 61, 260-263.

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