Development of Process Control Methodology for Tracking the Quality and Safety of Pain, Agitation, and Sedation Management in Critical Care Units

Walsh, Timothy; Kydonaki, Kalliopi; Lee, Robert J.; Everingham, Kirsty; Antonelli, Jean; Harkness, Ronald T.; Cole, Stephen J.; Quasim, Tara; Ruddy, James; McDougall, Marcia; Davidson, Alan; Rütherford, J. S.; Richards, J. R.; Weir, Christopher J.

doi:10.1097/ccm.0000000000001463

Cited by 7 publications

(7 citation statements)

References 41 publications

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“…The validity and reliability of the SQAT tool are reported separately. 12 The SQAT is shown in figure 1 .…”

Section: Study Overviewmentioning

confidence: 99%

“…These four measures were the most valid and reliable overall as metrics for describing sedation quality. 12 Importantly, we used SQAT fields to censor episodes of deep sedation that were potentially clinically indicated (for example: advanced ventilation strategies, therapeutic hypothermia, brain injury) and capture only unnecessary deep sedation counts. SQAT fields also enabled relevant denominator data to be captured, for example, ventilation status and presence of coma despite not receiving sedatives, to censure patients where appropriate during calculation of sedation quality metrics.…”

Section: Study Overviewmentioning

confidence: 99%

“…The development and a description of the process control charts took part in the early part of the DESIST research programme and have been described in detail separately. 12 …”

Section: Development and Description Of The Interventions Used In Thementioning

confidence: 99%

“…Given the absence of agreed methods for quantifying sedation quality and optimum sedation-analgesia for the purpose of clinical evaluations, we had to develop measures of sedation quality specifically for the trial. 12 We maximised efficiency by undertaking part of this work during the preintervention data collection period. Previous sedation trials have focused on metrics such as duration of mechanical ventilation and ICU stay, where the trial interventions were designed to minimise sedation use and deep sedation.…”

Section: Commentmentioning

confidence: 99%

“…Underpinning research completed during the early part of the research developed and validated the trial outcome measures, and one of the interventions used in the trial, and has been reported in detail separately. 12 The trial has completed recruitment (December 2014), and analysis and reporting is ongoing. This manuscript provides a detailed description of the development of the trial design and the methodological approach to analysis, which will complement the reporting of the study findings.…”

Section: Introductionmentioning

confidence: 99%

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Rationale, design and methodology of a trial evaluating three strategies designed to improve sedation quality in intensive care units (DESIST study)

et al. 2016

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Objectives: To describe the rationale, design and methodology for a trial of three novel interventions developed to improve sedation-analgesia quality in adult intensive care units (ICUs).Participants and Setting: 8 clusters, each a Scottish ICU. All mechanically ventilated sedated patients were potentially eligible for inclusion in data analysis.Design: Cluster randomised design in 8 ICUs, with ICUs randomised after 45 weeks baseline data collection to implement one of four intervention combinations: a web-based educational programme (2 ICUs); education plus regular sedation quality feedback using process control charts (2 ICUs); education plus a novel sedation monitoring technology (2 ICUs); or all three interventions. ICUs measured sedation-analgesia quality, relevant drug use and clinical outcomes, during a 45-week preintervention and 45-week postintervention period separated by an 8-week implementation period. The intended sample size was >100 patients per site per study period. Main Outcome measures:The primary outcome was the proportion of 12 h care periods with optimum sedation-analgesia, defined as the absence of agitation, unnecessary deep sedation, poor relaxation and poor ventilator synchronisation. Secondary outcomes were proportions of care periods with each of these four components of optimum sedation and rates of sedation-related adverse events. Sedative and analgesic drug use, and ICU and hospital outcomes were also measured.Analytic approach: Multilevel generalised linear regression mixed models will explore the effects of each intervention taking clustering into account, and adjusting for age, gender and APACHE II score. Sedation-analgesia quality outcomes will be explored at ICU level and individual patient level. A process evaluation using mixed methods including quantitative description of intervention implementation, focus groups and direct observation will provide explanatory information regarding any effects observed. Conclusions:The DESIST study uses a novel design to provide system-level evaluation of three contrasting complex interventions on sedation-analgesia quality. Recruitment is complete and analysis ongoing.

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“…The validity and reliability of the SQAT tool are reported separately. 12 The SQAT is shown in figure 1 .…”

Section: Study Overviewmentioning

confidence: 99%

Section: Study Overviewmentioning

confidence: 99%

“…The development and a description of the process control charts took part in the early part of the DESIST research programme and have been described in detail separately. 12 …”

Section: Development and Description Of The Interventions Used In Thementioning

confidence: 99%

Section: Commentmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Rationale, design and methodology of a trial evaluating three strategies designed to improve sedation quality in intensive care units (DESIST study)

et al. 2016

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Comfort and patient-centred care without excessive sedation: the eCASH concept

et al. 2016

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We propose an integrated and adaptable approach to improve patient care and clinical outcomes through analgesia and light sedation, initiated early during an episode of critical illness and as a priority of care. This strategy, which may be regarded as an evolution of the Pain, Agitation and Delirium guidelines, is conveyed in the mnemonic eCASH—early Comfort using Analgesia, minimal Sedatives and maximal Humane care. eCASH aims to establish optimal patient comfort with minimal sedation as the default presumption for intensive care unit (ICU) patients in the absence of recognised medical requirements for deeper sedation. Effective pain relief is the first priority for implementation of eCASH: we advocate flexible multimodal analgesia designed to minimise use of opioids. Sedation is secondary to pain relief and where possible should be based on agents that can be titrated to a prespecified target level that is subject to regular review and adjustment; routine use of benzodiazepines should be minimised. From the outset, the objective of sedation strategy is to eliminate the use of sedatives at the earliest medically justifiable opportunity. Effective analgesia and minimal sedation contribute to the larger aims of eCASH by facilitating promotion of sleep, early mobilization strategies and improved communication of patients with staff and relatives, all of which may be expected to assist rehabilitation and avoid isolation, confusion and possible long-term psychological complications of an ICU stay. eCASH represents a new paradigm for patient-centred care in the ICU. Some organizational challenges to the implementation of eCASH are identified.

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Staff education, regular sedation and analgesia quality feedback, and a sedation monitoring technology for improving sedation and analgesia quality for critically ill, mechanically ventilated patients: a cluster randomised trial

Walsh

Kydonaki

Antonelli

et al. 2016

The Lancet Respiratory Medicine

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Walsh, T. S. et al. (2016) Staff education, regular sedation and analgesia quality feedback, and a sedation monitoring technology for improving sedation and analgesia quality for critically ill, mechanically ventilated patients: a cluster randomised trial. Lancet Respiratory Medicine, 4(10), pp. 807-817. (doi:10.1016/S2213-2600(16)30178-3) This is the author's final accepted version.There may be differences between this version and the published version. You are advised to consult the publisher's version if you wish to cite from it.

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Development of Process Control Methodology for Tracking the Quality and Safety of Pain, Agitation, and Sedation Management in Critical Care Units

Abstract: Process control methodology can be used to simultaneously monitor multiple aspects of pain-sedation-agitation management within ICUs. Variation within and between ICUs could be used as triggers to explore practice variation, improve quality, and monitor this over time.

Cited by 7 publications

References 41 publications

Rationale, design and methodology of a trial evaluating three strategies designed to improve sedation quality in intensive care units (DESIST study)

Rationale, design and methodology of a trial evaluating three strategies designed to improve sedation quality in intensive care units (DESIST study)

Comfort and patient-centred care without excessive sedation: the eCASH concept

Staff education, regular sedation and analgesia quality feedback, and a sedation monitoring technology for improving sedation and analgesia quality for critically ill, mechanically ventilated patients: a cluster randomised trial

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