Introduction of sedative, analgesic, and neuromuscular blocking agent guidelines in a medical intensive care unit: Physician and nurse adherence

Objective: To determine physician and nurse adherence with sedative, analge sic, and neuromuscular blocking agent guidelines in the management of mecha nically ventilated patients in a medical intensive care unit. Design: Prospective cohort study. Subjects: One hundred consecutively admitted patients to a medical intensiv e care unit who required mechanical ventilatory support. A sample of 29 nur ses, residents, and attending physicians were interviewed regarding their a ttitudes and perceptions of the guidelines. Measurement: Data were collected from concurrent medical records and includ ed the following: demographic characteristics; clinical variables; physicia n prescriptions of sedative, analgesic, and/or neuromuscular blocking agent s; nurse administration of these medications; documentation of monitoring; and assessment of patient hemodynamic status and behaviors. A semistructure d interview was elicited from both nurses and physicians about their ration ale for the use or nonuse of the guidelines. Results: Patients ranged in age from 24 to 87 yrs, mean 60.7 (+/-15.3) yrs. Admission Acute Physiology and Chronic Health Evaluation III scores ranged from 36 to 192, mean 93.8 (+/-30.5) and median 88. Length of mechanical ve ntilatory support ranged from 1 to 112 days, mean 14.8 (+/-20.0) days, and median 8 days; medical intensive care unit length of stay ranged from 1 to 46 days, with a mean of 9.8 (+/-8.1) days and a median of 8 days. Of the 10 0 patients, 47% died, 28% returned home, and 25% were discharged to a nursi ng facility. Eighty-five patients were administered one or more sedative, a nalgesic, and/or neuromuscular blacking agent, range 1-9 drugs, mean 2.5 (/-1.5) drugs. Physicians prescribed 14 different medications; the most comm only administered drug was lorazepam (n = 71), followed by morphine (n = 39 ). Physicians and nurses had partial or total adherence to the guidelines i n 58% of patients. The initial choice of the drug followed the guidelines i n 60% of patients; the overall guideline was followed in 23% of patients. T he most common rationales far nonadherence to the guidelines stated by both physicians and nurses were patient-specific factors, resident guideline le arning curve, and physician medication preferences. Conclusion: Most patients required treatment for agitated behaviors. The ma jority of treatment regimens partially or totally adhered to the guidelines . Factors such as patient-specific disease states, resident guideline learn ing curve, and physician preferences of medications may have decreased adhe rence. Improving adherence to the guidelines is essential to assess their e ffectiveness in improving clinical outcomes.