The sedation scoring system and a one page protocol for sedation were developed and initially tested on a small sample of patients in the intensive care unit. The protocol was based on recently published scientific papers and adjusted to meet the local needs and traditions.1,2,8,10
They were then revised after the small scale experiments and questionnaires (table ). After the modifications, the guidelines were copied on coloured paper and posted at each bed in the intensive care unit.
Table 1 Cycles performed to develop and implement sedation protocol (November 1999-February 2001)
All adult patients (>18 years) who were treated on a ventilator for more than 24 hours were to be sedated in accordance with the new guidelines. The doctors defined the level of sedation desired twice a day, and the nurse in charge of a patient was then responsible for monitoring the sedation level using the scoring system and was allowed to adjust sedation according to the guidelines. This was new, and increased the nurses' responsibility for control of sedation.
The new guidelines were introduced in several ways. The reasons for the changes in practice were thoroughly explained to all staff. The doctors were invited to discuss modifications after the guidelines had been presented to them at several meetings, to attain a local consensus. The project group also presented the guidelines to the nurses at several meetings. To reach all nursing shifts, three identical presentations were made to the nurses. During the meetings, the rationale behind monitoring level of sedation and the pharmacology of the drugs used were discussed. The guidelines were also distributed by post and by personal emails to the staff, and displayed on a wall poster centrally located in the unit, which was regularly updated with results from the project. We also introduced an “FAQ” section (frequently asked questions—a familiar internet feature) on the poster, where important questions raised in discussions with the staff were answered. The project group also worked in the unit, making it possible for the staff to discuss at any time issues that might arise.
Measurement of problem
Baseline data were taken from the intensive care unit's clinical database (Regina), which has been in use for several years.11
Severity of illness was measured by the SAPS II scoring system.12
Ventilator time (measured in 24 hour days—for example, 6 hours=0.25 days), length of stay in the intensive care unit (in days), and mortality were also recorded. Our department has also operated a confidential reporting system for adverse events, making it possible to identify adverse effects that may be related to sedation practices.13
Data for each patient were collected and displayed graphically in the unit, allowing the staff to follow progress. Feedback was also provided regularly at staff meetings.
Data were analysed using statistical process control time series. Results were plotted in relation to time, to make direct visual evaluation possible.14
We calculated control limits for mean length of ventilation time before and after intervention and for length of stay in intensive care, and also mean differences and 95% confidence intervals.