A quality Improvement Project to Standardize Pain, Agitation, and withdrawal Assessments Reduces Usage of Morphine and Midazolam in the Pediatric Intensive Care Unit
CCCF ePoster library. Zavalkoff S. Nov 7, 2018; 234188; 10
Dr. Samara Zavalkoff
Dr. Samara Zavalkoff
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Introduction: Sedation in critically ill patients is often suboptimal. With over-sedation, it increases risk for iatrogenic withdrawal syndrome, delirium and may be associated with long term neurological impairment. Recent guidelines recommend that pain and sedation in critically ill children should be assessed and titrated sedatives and analgesics accordingly. We conducted a QI project to implement a routine standardized assessment of pain, agitation and withdrawal in our PICU

Objectives: To assess the impact of a quality improvement (QI) initiative to increase assessments of pain, agitation, and withdrawal on the use and cost of sedative and analgesic medication in a pediatric intensive care unit (PICU).


Design: Retrospective pre- and post- quality improvement study.

Setting: Eighteen-bed medical-surgical-cardiac tertiary PICU in an academic center.

Patients: PICU patients (0 - 18 years) consecutively admitted from October 1, 2015 to March 31, 2016 (pre- period) and from October 1, 2016 to March 31, 2017 (post- period) who were mechanically ventilated (MV) for more than 48 hours.

Intervention: QI initiative developed by a multidisciplinary team, including a family advisor, and implemented using rapid “Plan-Do-Study-Act cycles”, that 1) standardized assessment of pain and sedation, 2) standardized sedation goal setting, and 3) implemented the use of non-pharmacological strategies to manage pain and sedation. No specific sedation protocol was implemented. We used audit and feedback to reinforce change.

Measurements and main results: The post-intervention phase started once > 60% of patients had documented sedation scores q12h. Forty-five patients were included in each group. The groups were similar in age, weight, sex, PRISM III, and MV-day, but different in PICU stay (8 vs. 12 days, p 0.047). The cumulative dose of midazolam equivalent was significantly lower in the post-implementation period (3.71 vs 2.65 mg/kg/MV-day, p 0.009). There was a decreasing trending in morphine equivalent usage (3.51 vs 2.57 mg/kg/MV-day, p 0.066). There were no significant pre-post differences in the use of other sedative agents, rate of withdrawal, or medication cost.

Conclusions: A multi-faceted QI project to standardize formal assessments of pain and agitation resulted in a significant reduction in midazolam use. We also observed a decrease in morphine use without increasing rates of iatrogenic withdrawal syndrome.


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