579 - Adherence to sedative weaning recommendations is associated with decreased ICU length of stay

Publication Number: 579.3988

Taylor Smith, Boston Children's Hospital/Harvard Medical School, Cambridge, MA, United States; Soseh M. Hovasapian, Boston Children's Hospital, Boston, MA, United States; Franklin Ducatez, Boston Children's Hospital, Boston, MA, United States; John Kheir, Boston Children's Hospital, Boston, MA, United States; Barbara-Jo Achuff, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, United States

Background: Sedation and analgesia represent a significant and modifiable source of morbidity for critically ill infants and children. Minimizing doses and duration of exposure is critical to optimal outcomes. Exposure to opioids and benzodiazepines have each been shown to negatively impact neurodevelopmental outcomes in a dose-dependent fashion, particularly in vulnerable populations such as premature infants and children with congenital heart disease. Nurse-driven protocols offer promise for treatment standardization and dose reduction. However, many protocols are complex and difficult to follow in practice. The impact of protocol fidelity has been poorly characterized.

Objective: The purpose of this work was to quantify alignment of clinical practice with protocol recommendations for weaning of sedatives as well as the relationship between adherence and ICU length of stay (LOS) at two large children’s hospitals.

Design/Methods: All patients admitted to an intensive care unit (Pediatric ICU, Cardiac ICU, Medical-Surgical ICU, Medical ICU) at two institutions (Institution 1: 2018 – 2024; Institution 2: 2022 – 2024) that received one or more sedative infusions (including only morphine, hydromorphone, fentanyl, midazolam, dexmedetomidine), were intubated for > 24 hours, and did not have a tracheostomy present at admission were included. All infusion and bolus/as needed (PRN) doses of sedatives were extracted from the medication administration record. Weaning opportunities were identified per protocol recommendations. Broadly, any hour in which no sedative infusions were changed and < 3 PRN doses were given in the preceding 8-hour block represented an opportunity to wean (Figure 1). Percent adherence to weaning recommendations was calculated and relationship to ICU LOS was analyzed using linear regression.

Results: A total of 12,024 patients across 14,439 encounters were included. Overall, adherence to protocol recommendations for sedative weaning was low at both institutions, with weaning observed in 7.7% of opportunities at Institution 1 and 1.3% at Institution 2. Increased adherence was associated with decreased ICU LOS. A 10% increase in compliance correlated with a 3.1 day reduction in ICU LOS (R= – 0.14, p < 2.2e-16) (Figure 2).

Conclusion(s): Adherence to sedative weaning recommendations is poor. Improved weaning compliance is associated with decreased ICU length of stay. Further investigation regarding barriers to adherence and innovations that improve adherence are warranted.

Figure 1: Protocol recommendations for sedative weaning
Figure 1: Diagram illustrates protocol recommendation to decrease sedative infusion rate following 8-hour period with < 3 PRN doses and no change in infusion. Each hour without a recommended dose decrease represents a sedative weaning opportunity.

Figure 2: ICU length of stay and compliance with weaning recommendations
Figure 2. Increased compliance with recommended weaning (X- axis) is associated with decreased ICU length of stay (Y-axis) at both sites. Each point represents a patient encounter. Line and error represents linear regression line and 95% CI.