Simple Changes to Emergency Department Workflow Improve Analgesia in Mechanically Ventilated Patients

Abstract

IntroductionIn 2013 the Society for Critical Care Medicine (SCCM) published guidelines for the management of pain and agitation in the intensive care unit (ICU). These guidelines recommend using an analgesia-first strategy in mechanically ventilated patients as well as reducing the use of benzodiazepines. Benzodiazepines increase delirium in ICU patients thereby increasing ICU length of stay. We sought to determine whether a simple educational intervention for emergency department (ED) staff, as well as two simple changes in workflow, would improve adherence to the SCCM guidelines.MethodsThis was a cohort study that took place from 2014–2016. All patients who were intubated in the ED by an emergency physician (EP) during this time were eligible for inclusion in this study. In January 2015, we began an educational campaign with the ED staff consisting of a series of presentations and online trainings. The impetus for our educational campaign was to have best practices in place for our new emergency medicine residency program starting in July 2016. We made two minor changes in our ED workflow to support this educational objective. First, fentanyl infusions were stocked in the ED. Second, we instituted a medication order set for mechanically ventilated patients. This order set nudged EPs to choose medications consistent with the SCCM guidelines. We then evaluated the use of opioids and benzodiazepines in mechanically ventilated patients from 2014 through 2016 using Fisher’s exact test. All analyses were conducted in the overall sample (n=509) as well as in subgroups after excluding patients with seizures/status epilepticus as their primary admission diagnosis (n=461).ResultsIn 2014 prior to the interventions, 41% of mechanically ventilated patients received an opioid, either as an intravenous (IV) push or IV infusion. In 2015 immediately after the intervention, 71% of patients received an opioid and 64% received an opioid in 2016. The use of benzodiazepine infusions decreased from 22% in 2014 to 7% in 2015 to 1% in 2016.ConclusionA brief educational intervention along with two simple changes in ED workflow can improve compliance with the SCCM guidelines for the management of pain and agitation in mechanically ventilated patients.

Nudging clinicians: A systematic scoping review of the literature

“…Of the 11 community‐based studies, five (45%) were randomized controlled trials, 38,45‐48 one was cluster‐randomized, 43 one was quasi‐randomized (alternate weeks), 39 and the remaining four (36%) were pre‐post studies40‐42,44: two single‐site and two multi‐site with controls (one with randomized allocation to intervention, the other unclear). Of the 11 hospital‐based studies, seven were single site pre‐post comparisons, 49‐52,54,56,59 one was a two site pre‐post comparison without a control, 53 one was a multi‐site pre‐post with one site non‐randomly allocated to intervention, 57 one was a multi‐site with multiple interventions rolled out at different times (non‐uniformly) across sites, 58 and one was a qualitative study 55 . We summarize the study types in Table 3.…”

“…The single peer comparison study reporting absolute differences in proportion 45 resulted in a small change of 6%. Studies using workflow re‐direct nudges (time/cost saving) reported significant absolute changes in proportions ranging from 20% to 30% 54,57 …”

“…Soon et al refer to this as a “double nudge.” 47 Default alert to increase compliance with best practice ventilation for patients in ICU increased in effectiveness, for example, when paired with audit and feedback implementation. We note, however, that education modules introduced prior to implementing a nudge intervention were not always accounted for in the assessment of outcomes or defined as a control 54,59 …”

A Systematic Review of Nudge Interventions to Optimize Medication Prescribing

“…A list of these articles and the reasons for their exclusions are provided in Supplementary Appendix 2 . Ultimately, 15 articles that evaluated interventions to optimize prescribing were included ( Bourdeaux et al, 2014 ; Harewood et al, 2011 ; Isenberg et al, 2018 ; Lemiengre et al, 2018 ; Mafi et al, 2018 ; Malhotra et al, 2016 ; Meeker et al, 2014 ; Musgrove et al, 2018 ; O'Connor et al, 2009 ; Patel et al, 2018 ; Patel et al, 2017 ; Presseau et al, 2018 ; Sacarny et al, 2018 ; Shakespeare et al, 2019 ; Yadav et al, 2019 ).…”

“…Only two of the interventions applied a sufficient array of recommended techniques to address all identified determinants, and only one of these interventions was effective. Regarding the effective intervention, Isenberg et al ( Isenberg et al, 2018 ) noted that emergency department practitioners may not be aware of new guidelines published around pain management for mechanically ventilated patients and that workflow inadequacies may be preventing optimal analgesic and benzodiazepine use. To build practitioners’ knowledge, they provided feedback on their current prescribing and instructions about how to follow the new guidelines.…”