So I'll just do a quick introduction. My name is Kathleen Bowman. I'm a clinical nurse specialist consultant. I spent 13 years at Henry Ford Hospital in the medical intensive care units as the clinical nurse specialist doing one of the first 40 hospital testing of the vent bundle. So a lot of early work. Our first pain, anxiety, not agitation, delirium protocols that we developed were in 1993 for our medical intensive care and that was literally out of necessity because our patients weren't getting pain managed and they were getting one milligram of Ativan which was not enough to address some of the challenges. So no real disclosures for this particular presentation but I did put in the past some of the work that I've done. What are we going to do during this time that I have and Wes is review some of the current evidence related to the hazards of deep sedation and some of the benefits of the SAT-SBT approach and some of that was already addressed for you. Looking at those reliable and valid tools to use in the clinical environment to be able to assess the anxiety, arousal, sedation, however we want to phrase that. Providing practical guidance on the SAT and Wes is going to spend more time on the SBT but understanding straight out of the chute this is an absolutely collaborative effort. You will not succeed if those two don't partner together well and so that's a critical component and we'll talk about some of those barriers. So what are we looking for when we are going after goals of sedation? We've talked about a RAF between a minus one and a plus one but literally we're looking for a relatively calm individual, cooperative, engaging. They don't have anxiety or the anxiety is significantly reduced. They're syncing with their ventilator as much as possible and we also want to make sure that this experience doesn't leave significant mental health and traumatic memories of things in the intensive care unit. So looking at it, how many have heard of sedation vacation? All of these kind of things. I think it's important for us to really stick to spontaneous awakening trial because when we do sedation vacation, what does that conjure up in your head? Oh I'm gonna take and boom and the patient's gonna have a vacation and go off to the beach. No only kidding, but it conjures up something different versus a very specific act that we are doing to make the right thing happen for the patient. So there is an actual definition for a spontaneous awakening trial. It is a period during which sedative medications that were previously being used to treat an ICU patient are held. So this is specific health. So even if they're at a zero on whatever dose they're on, the concept is to remove that or hold it to determine whether the patient requires ongoing sedation or if we can manage them completely off sedation. So what do we define as adequate sedation? Through the years this has been sort of all over the place. When you look at research studies of self-reporting of the various clinicians of what they view as sedated or not, this was a 274 patient study observation where the majority, 85 percent of the patients over four-hour intervals had received sedative medications during mechanical ventilation and literally one out of three were unarousable during that time. By the way, just to put this in context, this was around 2008-2009 so that it gives you sort of where we were in our journey. 22 percent at the point of observation had no spontaneous motor activity. So we're talking deep, deep on the sedation which is not good. Now interesting enough, they did a judgment observation and 14 percent of the nursing staff thought the patients were under sedated in this environment. 83 percent felt adequately sedated and if you look, one in three are unarousable. That's classified as adequately sedated. So we have to change what that view definition looks like in our environment. There was only two point six percent that thought they were over sedated. So the Canadian group, they've published a couple studies now. This was in a two-week observational study, 51 intensive care units across Canada, 712 patients and it was interesting in this observation, were you guys a part of this? Okay. Yeah, they found that nearly all the patients were managed with a continuous infusion. So I want you to keep that in your head because that's a behavior, if we can remove or reduce significantly, is an important component of this journey, both of opioids and sedatives. They found that the actual practice was significantly different from what they expected. So almost all of these environments had protocols, had assessment tools, had all of that, but they weren't being used. If you take a look at this, sedation scale was only being used half the time, pain scale only 20 percent, delirium scale 5.2 percent, protocols 25 percent, and an awakening trial about 51 or about 42 percent of the time. So what we believe is happening in our environments may not always be happening, which is why measurement is so critical in this journey, repeat measurement. So what are some of the consequences of this deep and long prolonged sedation versus light sedation? Wes talked about this. Reduce six-month survival if hospital mortality is increased, longer duration on the breathing machine, longer stay in the ICU, and then the post traumatic stress syndrome, the increased delirious and memory components that come with it. So there is clearly a negative sequelae that happens with it. This was a study published in the Blue Journal. Again, it was done around 2009-ish, so I want to put it in where we are in this journey. They did for first 48 hours deep sedation and that was that was viewed as a RAS of minus 3 to minus 5. Then they looked at what happened versus not doing it. What they found is time to extubation was significantly longer even in the first two days. So our practice of, oh they got to be snowed right in the beginning, you know, to get everything stabilized causes harm. And so again, changing that culture and then 180 day time to mortality was impacted. What I found really profound about this data is for every RAS that was taken Q4 hours, that was in a deep sedation level, it added 12 hours to extubation and also added a 10% increased risk to hospital death. So I thought that was pretty powerful data that you can utilize to convince souls that believe that this needs to be controlled versus using assessment tools to allow the management of it. So what happens to the mental health after lighter deep sedation? So this was a randomized controlled trial looking at 137 adults. At this point they were using the RAMSI. There's some challenges with the RAMSI tool in the fact that it spends most of its time on the over sedated and not enough on the agitation. So it tends to be a bit more of a challenge, but in the light RAMSI, one to two, they did intermittent injections. In the heavier RAMSI, you know, to where the patient was more sedated, they had continuous infusion. And then they looked at primary endpoints at four weeks, what was going on with these patients, trend towards more post-traumatic stress syndrome, more trouble remembering the events, more disturbing memories of the intensive care unit. This study did not do anxiety or depression scores as a part of it. Other endpoints, and it's exciting to see that we see the negative of the deep, but now we also see the positive of the light. On the light sedation, one day shorter mechanical ventilation and 1.5 days shorter length of stay. And I know it's been mentioned a few times, but I think it's important in our data that we also put cost to this because there's always resources necessary for education and for other components and measurement and those pieces. And I think if we can cost-justify as well as showing the clinical outcomes for the patient, it makes a difference. Now to talk about one of the issues that was brought up in terms of a nurse-implemented sedation protocol. This was published in the late 90s and it was one of the limitations. It was a single center, but it was an extremely well done study. And what they found is a nurse-implemented sedation protocol resulted in less sedation. It resulted in shorter time on the ventilator, shorter time in the ICU, and shorter time in the hospital. It also resulted in less continuous infusions versus intermittent. And this is where we started to see a relationship of trying to move away from the continuous infusion because of the amount of sedation. And I will tell you from a nurse perspective, if I have to push something versus going up and down on a drip, I am more conscious of the evaluation I do with the patient than I am with that drip. I don't know the psychological principles of that, not exactly sure, but that is an absolute reality in the clinical environment. Now this is another study. So we don't just have one study, we have multiple studies looking at the impact of a nurse-implemented sedation protocol. And this one, the main target was looking at reducing ventilator-associated pneumonia and that gets reduced when you get them off the vent and they're awake and moving around and doing other things. But as you can see here, the midazolam, even though they were using a benzodiazepine, again you have to look at the timing of this. This was published in 2007. So the midazolam dose was significantly lower when the patient was with the protocol. Two-day reduction in the amount of hours on the midazolam, less reintubation actually. So those fears that staff talk about, about sedation management and early wake-up and those that we're going to have more extubation and those kinds of things, there is data here for you guys to utilize in convincing your team with scientific evidence, if they are the qualitative or the quantitative kind of people, that it does make a difference. And they were able to show duration of mechanical ventilation, reduction in ICU stay, and hospital length of stay. Are you seeing a theme here? Yeah, pretty much the same outcomes in almost all of these. This was a pharmacy-guided. So how many of you have active pharmacy in rounds and a pharmacist designated to the environment? This is another person where you may have a nurse-driven protocol with a pharmacy backup and have the interface of the two. And they were able to show, one, they were able to identify alcohol challenges that were going on that may be contributing to this whole process. That was part of it. They also had a significantly lower or not significantly lower lorazepam dose, but they did have a significantly lower fentanyl dose. But they also saw in the difference between usual care and pharmacy-controlled or pharmacy-integrated was duration of mechanical ventilation, ICU length of stay, and hospital length of stay. And then Wes mentioned this trial, the CREST trial, which was some of the seminal work on the spontaneous awakening trial. And most of us follow this where we will hold sedation until the patient awakes. One of the things we've changed is we're not necessarily restarting it unless the patient needs it restarted. So it's just not an automatic on the restart. And the awake was defined as doing three of the following things. And I would hope that when you build your protocol that these are the these are part of your yes positive response that the awakening trial worked. Open eyes in response to voice, eyes to following investigator, squeeze the hand, and stick out the tongue. Now interesting, the data showed same thing. Ventilator reduction, ICU length of stay, and the other thing that happened with this research is we didn't do as many CAT scans because the people were not unarousable. And then the differential did not have to go down that path as a part of the journey. So I'm going to leave more of the exact guts of the ABC trial to Wes, but I did want to point this is where the merge of the two because we had SBT trial data before we had the SAT and then the ABC trial put it together. And the power of the data, and Wes you probably have this slide, if you take a look doing the SBT alone and then you add the SAT to the SBT, the compounding improvement that you see than just doing the SBT alone is huge across the board on all measures. And I will tell you I think the ABC trial is one of the seminal besides the outcome data from the ICU collaboratives to show that the partnering of these two are synergistic and need to work together and can't be separate. And when we talk about measures, one of the measures you're going to be looking at potentially, and if it's not on the sheet, it's one of the things to consider, how many SBTs were done off sedation so that you know the two are partnering together as a part of it. So interesting enough, this was a study published in 2012 and it was a negative trial. So it was a multi-center randomized control protocolized sedation versus protocolized sedation with a spontaneous awakening trial. Interesting, when you get into the guts of the study, what they found is the people that got the spontaneous awakening trial got more drugs afterwards. And so whatever criteria was used to put them back on or or to re-dose resulted in an increase in the amount of sedation. So it makes sense why this would ultimately be a negative trial because the message we're going after is primary avoidance of unnecessary sedation. So if I'm actually put more on as a result of something, I'm sort of losing my purpose. So when I look at agitation, how many are doing this every four in the environment? And again using the term anxiety versus agitation, the two validated tools RAS and SAS, is anybody using anything different? Okay, so that change has occurred. That's awesome. And how many remember the RAS target in the first PAD guidelines, minus two to plus one? Now they haven't officially changed in the PAD-S guidelines, but what has happened in our culture is recognizing that minus two is still too sedated. And so we're really targeting that zero plus one minus one, just that small, small range there. And if you use SAS, three to four is where you're targeting. Now it's beyond the scope. You guys are familiar with on these tools? You're also going to get familiar during the demonstrations too. But the concept of, and I believe we're using the RAS in in the simulation, but and so I'm going to go to that one, the concept here is looking at getting in the middle, not at not over agitated or anxious, and not somnolent. And so that's why this tool works so well, is because the middle makes sense to people. And we don't like extremes on either side as a part of that journey. So how do you facilitate reliable performance of the SATs? I wanted to include the PAD-IS statements that have come out. We suggest use of light sedation versus deep sedation in critically ill mechanically ventilated patients. It is a conditional low recommendation, but I think it is something based on the research that Wes talked about and the research presented here that I can feel comfortable saying we want to go after light versus deep. Deep causes harm. The other, we suggest using propofol over benzodiazepines in cardiac surgery patients. And we suggest using propofol or dexamethetomidine over benzodiazepines in overall sedation of mechanically ventilated patients. So how many are still experiencing, outside the world of alcohol withdrawal, routine use of benzodiazepines in the environment? That is a tough nut to crack as a part of it. So I would get those PAD guidelines, get the individual research when you're in your teams, not necessarily teaching the course, but when you're facilitating implementation of this in your environment and have those studies in your pocket to have those discussions and then work towards, through your multidisciplinary team, removal of it from the protocols as a part of that journey. So in critically ill adult patients, it is an ungraded statement but it's recommended to implement a spontaneous awakening trial and a nurse driven sedation protocol to achieve and maintain the light sedation. The challenge is if the nurse every time has to go through calling the physician to achieve, the amount of time that takes in the process becomes a challenge in achieving that light sedation, in achieving the goal we're going after. Anybody using BIS monitoring? So they made a recommendation. It is an ungraded statement that it is best suited when you're using deep sedation for respiratory or you've got a neuromuscular blockade on as a way to assess so that you don't get them too deep as a part of it. So target level of consciousness, how many during your multidisciplinary rounds are you redoing targets or is everybody going from their protocol and then a discussion is the target the same as the protocol? Because that is a critical component whether you use fast hugs, you actually incorporate A through F in your rounding structure to be able to ask that question if it is off the normal target so that the team knows what the goal is as a part of it. So this look familiar to everybody? It's that combination of the wake-up and breeze of the SAT and SBT and by the way all of these protocols are available on multiple websites. You can pretty much find them anywhere so you really don't have to reinvent the wheel as a part of it but sometimes you really do have to trust the process. I will tell you we implemented SBTs. We had already had a sedation agitation and delirium protocols in and we finally were successful at implementing the SBT component but I got to tell you it almost took an act of God to get respiratory to change from 6 in the morning to 8 in the morning. So one of the things and in the international world you may have not have to deal because you may not have respiratory therapists so that may not be as big of a challenge but that coordination is a critical component to this and so one of the things when I have to change people's systems, one of the things I do is I put a patient in the center and I say are we doing this activity for us or are we doing this activity for the patient and what's best for the patient and by the way that goes bathing at 3 30 in the morning. Another practice that nurses have to get rid of. So on the SAT you start it so the timing and a lot of people choose that 7 30 8 o'clock right after the nurses have done shift report so that they can be in the room and make that assessment and they've coordinated with respiratory therapy but in all of these both the SAT and SBT they do safety screens and this is allowing us for the staff to feel comfortable that we are not going to do this on a patient that has significant issues going on. No active seizures, no active alcohol withdrawal, not flagging around, no paralytics going on, myocardial ischemia or and they have a normal intracranial pressure. In terms of failure, failure is they are experiencing significant agitation or pain with it. They have a respiratory failure component to this, respiratory distress or an acute cardiac arrhythmia as a part of it. Now your group as you work may have some additional exclusion criteria. These are some that have been published in the literature. The other ones that I showed you are the ones from most of the trials but these are some over time that people have felt comfortable adding without taking away from doing this with most most patients as a part of it. So if they pass the SAT, how do we know? They can do three out of four of these. Again like pain assessment, like RAS assessment, like delirium assessment, you got a coach. You got a coach on this doing that test to change process. If they can also, another criteria if they can go four hours without sedation is a part of it. So what do we do if they pass or fail? Don't re-sedate if they pass. Don't start it back up. It's going to be a hard one. Don't do it. If they fail, restart it at half the dose, not the full. Needless to say, if they pass you then move to the coordination of the SBT. So when you look at the ABC trial, only 4.7% agitation during the SAT. So this is a slide that I would use to help address some of those fears that exist with the staff. Literally breaking out what they saw during the awakening component of the ABC trial. So we talked about restarting titrate to goal and if needed doing a bolus dose of an anti-anxiolytic in order to address it if you are dealing with the plus four level agitation where there is potential harm. Things to consider, some barriers concerned by the staff. I think a lot of you brought this up and this is where using the test to change and the coaching will assist. By the way, you are changing the standard of care in your environment. This is going to take longer than probably any change project that's been done. The one thing the staff need to know, this is not a flavor of the month. This is the new way we're doing business in order to improve it. Workload productivity concerns, again the coordination. There is fear of the patient discomfort, asynchrony. I shared with you that data. It really doesn't show up and Wes talked about the fact that we remember the party of one patient that had a bad experience and so we have to be able to counteract that with all the good experience. By the way, most of this SAT-SBT was created so that the patient who knew they were ready to extubate don't self-extubate. We actually do it for them. The other group was we weaned all day and at 430 in the afternoon we said, ah it looks like we could take the tube out and then somebody says, oh there's not enough staff. Then in the middle of the night they vomit or they aspirate and they're back on the ventilator. That's really the target of this group. In looking at, there is data looking at barriers for sedation protocols and daily interruption or the spontaneous awakening trial. This was a web-based survey. Reasons for lack of protocol use, no physician order. By the way, I think that was discussed having an automatic and have them have to deselect versus select. Lack of nursing support was only about 11% and fear of over sedation was about 7%. In terms of the daily interruption, nursing acceptance, and that takes the coaching, risk of device removal, and by the way there has been shown device removal happens. But guess what? It doesn't go back in because the patient pretty much knew it was time. We just hadn't gotten to it yet. Respiratory compromise is real and patient discomfort, but I think we can address that. How do you facilitate the success? It takes a team. It can't be just one discipline. It really takes a coordinated effort. That coordination is critical and that's where sitting down with this team and discussing that and then following through with it. Having each member of the team speak up about the component that they own, sort of, in rounds so that everybody feels respected and engaged as a part of this journey. Post your data. Literally when we started that, when we added the SBT to our other work, we went seven points under the trend line. But everybody thought we were awesome at our ventilator days and they were able to see an improvement. Extubation rates posted. Make sure everything aligns with the goals that you're working on.

deep sedation

SAT-SBT approach

intensive care unit

reliable tools

light sedation

patient outcomes