Pain, Agitation, and Delirium Guidelines: Implications Within a Community Hospital

Background:

A new order set addressing sedation, analgesia, and delirium was developed referencing the updated Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit (PAD Guidelines) which was recently published by the Society of Critical Care Medicine (SCCM) while assessing the clinical impact and outcome metrics.

Methods:

A retrospective chart review was conducted on adult patients admitted to our community hospital that were mechanically ventilated between September 2011 to March 2012 and September 2012 to March 2013. Excluded patients were those < 18 years of age and admission to the surgical trauma intensive care unit (ICU) or cardiovascular ICU. Data collection included demographics, laboratory, ventilator, medication, and fiscal parameters. Patients were divided into two groups based on if the new guidelines were applied or not. The primary endpoints were duration of mechanical ventilation, rate of ventilator associated pneumonia (VAP), medication and hospital related costs, sedative selection and utilization, length of hospitalization, and 30‐day readmission rates. Descriptive statistics were used for baseline demographics consisting of continuous and discrete variables.

Results:

A total of 1274 patients were evaluated. Baseline characteristics between each arm analyzed were similar. Post‐implementation of the PAD guidelines, all outcome metrics evaluated showed improvement excluding medication costs. The duration of mechanical ventilation decreased 17.6% across the measured units. The rate of VAP declined from 23.9 cases per 1,000 ventilator hours to 10.6 in the intervention group. Average medication cost increased from $25,775 to $28,070 in the intervention group; however, total hospital costs were reduced from $27,319 to $23,733. There was a modest decline in the average ICU stay from 6.99 days to 6.73, but total duration of hospitalization decreased from 14.9 to 11.3 days. Patients included in the intervention group experienced a lower 30 day readmission rate compared to the pre‐intervention group 11.96% versus 9.15%, respectively.

Conclusions:

The implementation of the recently revised PAD guidelines increased awareness and documentation of delirium, prompted the initiation of non‐pharmacologic and pharmacologic interventions for the treatment of delirium, decreased the duration of mechanical ventilation, lead to a reduction in VAP rates, decreased total hospital cost, increased the use of non‐benzodiazepine sedatives, decreased length of hospitalization, and decreased 30‐day readmissions. Through the work of an interdisciplinary taskforce, our institution was successful in implementing the recommendations detailed in the SCCM PAD Guidelines to achieve improved patient care and fiscal outcomes.