multifaceted approach to improve hand hygiene practices in the adult intensive care unit of a tertiary-care center

A multidisciplinary team was formed to improve hand hygiene [HH] practices in a tertiary-care ICU. At baseline, an audit revealed that the overall HH compliance was 64% and was significantly lower at night than during the day shift. After implementing a stepwise multifaceted approach that included education, workplace reminders, active feedback and later universal contact precautions, the HH compliance improved significantly to >80%, and the improvement was sustained over several months. This improvement was noted during the day and night and affected different healthcare workers as well as visitors

Sedation in ICU: are we achieving goals?

The purpose of this study was to examine whether sedation goals, utilizing a validated sedation assessment scale, the Riker Sedation-Agitation Scale [SAS], and a standardized sedation protocol, were achieved in Intensive Care Unit [ICU] patients. This is a nested prospective cohort study. The study was conducted in a tertiary care medical-surgical ICU. All mechanically ventilated adult patients who were judged by their treating intensivists to require intravenous sedation for more than 24 hours, were included in the study. A goal-directed protocol using the SAS was initiated following an educational program to the medical and nursing staff. The following data was collected: patients' demographics, Acute Physiology and Chronic Health Evaluation [APACHE] II score, reason for admission, and outcome. For the first five ICU days, the bedside nurse documented ordered and average achieved SAS scores, every 4 hours. We compared the targeted versus achieved SAS scores using a paired Student's t-test. One hundred and five [105] patients were included in the study with mean age [ +/- SD] of 47 [ +/- 23] and APACHE II [ +/- SD] of 21 [ +/- 9]. Achieved sedation scores were consistently lower than the requested goals during daytime and nighttime shifts throughout the study period. This did not change even after 3 months of implementing the protocol. Achieved levels of SAS score were consistently lower than what was requested by physicians despite an educational program and the use of a standardized protocol. Differences between targeted and achieved SAS scores persisted throughout the whole study period even three months after protocol implementation. These data suggest the need for alternative, more sensitive and precise approaches, to titrate sedation to targeted levels

Changing sedation practices in the intensive care unit- protocol implementation, multifaceted multidisciplinary approach and teamwork

Sedation protocols have demonstrated effectiveness in improving ICU sedation practices. However, the importance of multifaceted multidisciplinary approach on the success of such protocols has not been fully examined. The study was conducted in a tertiary care medical-surgical ICU as a prospective, 4-pronged, observational study describing a quality improvement initiative that employs 2 types of controlled comparisons: a [before and after] comparison related to intense education of ICU clinicians and nurses about sedation and analgesia in the ICU, and a comparison of protocolized versus non-protocolized care. Patients were assigned alternatively to receive sedation by a goal-directed protocol using the Riker Sedation-Agitation Scale [SAS] or by standard practice. A multifaceted multidisciplinary educational program was initiated including the use of point of use reminders, directed educational efforts, and opinion leaders. This included several lectures and in-services and the routine availability of at least one member of this group to answer questions. We included all consecutive patients receiving mechanical ventilation, who were judged by their treating team to require intravenous sedation. The following data was collected: demographics, Acute Physiology and Chronic Health Evaluation [APACHE] II score and Simplified Acute Physiology score [SAPS] II, daily doses of analgesics and sedatives, duration of mechanical ventilation, ICU length of stay [LOS] and ventilator associated pneumonia [VAP] incidence. To examine the effect of the multifaceted multidisciplinary approach, we compared the first 3 months to the second 3 months in the following 4 groups: Gl no protocol group in the first 3 months, G2 protocol group in first 3 months, G3 no protocol group in the second 3 months, G4 protocol group in the second 3 months. After ICU day 3, SAS in the groups G2, G3 and G4 became higher than in Gl reflecting [lighter] levels of sedation. There were significant reductions in the use of analgesics and sedatives in the protocol group after 3 months. This was associated with a reduction in VAP rate and trends towards shorter mechanical ventilation duration and hospital length of stay [LOS]. The implementation of a multifaceted multidisciplinary approach including the use of point of use reminders, directed educational efforts, and opinion leaders along with sedation protocol led to significant changes in sedation practices and improvement in patients' outcomes. Such approach appears to be critical for the success of ICU sedation protocol