Current practices and barriers impairing physicians' and nurses' adherence to analgo-sedation recommendations in the intensive care unit--a national survey.

INTRODUCTION

Appropriate management of analgo-sedation in the intensive care unit (ICU) is associated with improved patient outcomes. Our objectives were: a) to describe utilization of analgo-sedation regimens and strategies (assessment using scales, protocolized analgo-sedation and daily sedation interruption (DSI)) and b) to describe and compare perceptions challenging utilization of these strategies, amongst physicians and nurses.

METHODS

In the 101 adult ICUs in Belgium, we surveyed all physicians and a sample of seven nurses per ICU. A multidisciplinary team designed a survey tool based on a previous qualitative study and a literature review. The latter was available in paper (for nurses essentially) and web based (for physicians). Topics addressed included: practices, perceptions regarding recommended strategies and demographics. Pre-testing involved respondents' debriefings and test re-test reliability. Four reminders were sent.

RESULTS

Response rate was 60% (898/1,491 participants) representing 94% (95/101) of all hospitals. Protocols were available to 31% of respondents. Validated scales to monitor pain in patients unable to self-report and to monitor sedation were available to 11% and 75% of respondents, respectively. Frequency of use of sedation scales varied (never to hourly). More physicians than nurses agreed with statements reporting benefits of sedation scales, including: increased autonomy for nurses (82% versus 68%, P < 0.001), enhancement of their role (84% versus 66%, P < 0.001), aid in monitoring administration of sedatives (83% versus 68%, P < 0.001), and cost control (54% versus 29%, P < 0.001). DSI was used in less than 25% of patients for 75% of respondents. More nurses than physicians indicated DSI is contra-indicated in hemodynamic instability (66% versus 53%, P < 0.001) and complicated weaning from mechanical ventilation (47% versus 29%, P < 0.001). Conversely, more physicians than nurses indicated contra-indications including: seizures (56% versus 40%, P < 0.001) and refractory intracranial hypertension (90% versus 83%, P < 0.001). More nurses than physicians agreed with statements reporting DSI impairs patient comfort (60% versus 37%, P < 0.001) and increases complications such as self-extubation (82% versus 69%, P < 0.001).

CONCLUSIONS

Current analgo-sedation practices leave room for improvement. Physicians and nurses meet different challenges in using appropriate analgo-sedation strategies. Implementational interventions must be tailored according to profession.