Daily sedation interruption (DSI, also called a sedation vacation) can be beneficial for mechanically ventilated patients. This article focuses on what nurses need to know about DSI so that evidence-based guidelines are followed when sedatives and analgesics are stopped temporarily.1
Our facility's surgical ICU launched a quality improvement project (see About QSEN) to enhance nurse education about DSI in mechanically ventilated patients. The need for education was identified by the unit manager and medical record audits showing that nurses were documenting DSI on only 30% of the medical records reviewed.
Why education matters
The current science supporting DSI may be confusing, so keeping nurses up-to-date on continuous sedation in mechanically ventilated patients is a priority. Mechanically ventilated patients often experience pain from endotracheal suctioning, mechanical ventilation, surgical incisions, indwelling catheters, and repositioning in bed.2 The discomfort from these factors results in patients requiring I.V. continuous sedation (which includes analgesia). DSI is needed so that you can assess the patient's neurologic status and determine the necessity for continuation of sedation.
Evidence-based practice recommends interrupting sedation at least daily in mechanically ventilated patients to evaluate patient need for remaining on I.V. continuous sedation.1,2 Benefits of DSI include the ability to accurately titrate sedation, which reduces time on mechanical ventilation, length of ICU stay, risk of ventilator-associated pneumonia, and need for neurologic diagnostic tests related to oversedation.1 Patients receiving DSI reported that they're better-able to cope with their illness and experienced less posttraumatic stress disorder symptoms associated with the painful and frightening experience of being intubated and mechanically ventilated.1
Your role
At our facility, 25 nurses participated in a collegial interview to assess their knowledge of DSI, current practice, and obstacles to performing DSI. Here are the most common responses to questions asked about DSI in interviews at our facility:
* How often do you perform DSI-never, sometimes, or always? Sometimes.
* If you don't perform DSI, why not? Patient is already following commands.
* For what duration should you perform DSI? Until the patient wakes up.
* How often should DSI be performed? Each shift. (That is, every 12 hours rather than every 24 hours as recommended by evidence-based practice.)
* What is the benefit of DSI? Accurate neurologic assessment.
* What is the obstacle to performing DSI? Documentation is cumbersome.
The responses indicated that nurses weren't implementing DSI every time, and that confusion surrounded implementing prescriptions for DSI and contraindications to DSI. The responses also indicated a lack of knowledge of all the benefits of DSI; most nurses thought that DSI was only indicated for accurate neurologic assessment. Generally, most of our surgical critical care nurses reported that they were hesitant to interrupt sedation because they feared patients would experience excess pain, be too awake, and possibly injure themselves by self-extubation or removal of invasive lines. An educational review for nurses was needed to share the evidence about DSI, including its many benefits.
Learning about DSI
Before educating our nursing staff, we conducted a pretest (see Testing nurses' knowledge of DSI). Subsequently, we created an educational bulletin board about DSI, including a recommended evidence-based sedation interruption protocol. Our next step was one-on-one education with the staff to reinforce learning. Third, a staff development slideshow (replicating the educational bulletin board) was presented at a unit-based leadership council to surgical ICU colleagues. Finally, informal discussions were held during all shifts to reinforce key points and evidence-based practice about DSI. Following all educational steps, a DSI posttest (a repeat of the pretest), was conducted during a unit-based meeting to determine if educational interventions were effective.
Assessing the educational trip
Our project sought to raise awareness and provide education to nurses to better care for patients by correctly performing DSI. The project's main goal was to improve patient outcomes.
The average pretest score was 83%; the average posttest score was 96%. The significant improvement in posttest results indicated the success of the DSI education. Although we plan to ensure ongoing education to reinforce evidence-based DSI practice, this project provided a significant step toward delivering optimal patient-centered care. This quality initiative also presented an opportunity for nursing staff growth and opened the door for further discussion within our team. For example, how will we continue to monitor the established DSI protocol to ensure continued performance? Because nurses found that documenting the administration of DSI is cumbersome, one of our next steps in our ongoing quality process will be a focus on documentation. In summary, based on evidence-based research, sedation vacations are worth the trip, and so was this quality improvement project.
About QSEN
QSEN, funded by the Robert Wood Johnson Foundation, aims to prepare future nurses with the knowledge, skills, and attitudes needed to continuously improve healthcare system quality and safety.
The first phase of the project identified six competencies: patient-centered care, evidence-based practice, quality improvement, teamwork, safety, and informatics. In the second phase, pilot schools integrated these competencies in their nursing programs and shared their teaching strategies and resources on the QSEN website (http://www.qsen.org).
The third phase, which started in November 2008, aims to continue promoting innovation in teaching the six competencies, developing faculty expertise, and creating ways to improve all nursing programs through the content in textbooks, accreditation and certification standards, licensure exams, and continued competence requirements.
Source: Quality and Safety Education for Nurses, http://www.qsen.org/overview.php.
Testing nurses' knowledge of DSI
This test was administered as a pre- and posttest in our quality improvement project.
1. How long should DSI last?
a. 10 minutes
b. 20 minutes
c. until patient follows commands
d. until patient exhibits agitation
e. c and d
2. Circle all common benefits of daily sedation interruption.
a. ecreased length of time of ventilation
b. ecreased length of ICU stay
c. ncreased sedation
d. ecreased other complications, such as ventilator-associated pneumonia and central line-associated bloodstream infection.
e. decreased anxiety
3. Whichisn'ta potential adverse reaction to DSI?
a. psychedelic dreams
b. self-extubation
c. pain
d. anxiety
e. rebound agitation
4. DSI is better for acute posttraumatic stress disorder.
a. true
b. false
5. Do you think DSI is important for your patients?
a. yes
b. no
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