Date of Award

2014

Document type

Thesis

Degree Name

PhD (Doctor of Philosophy)

First Supervisor

Professor Seamus Cowman

Second Supervisor

Dr Dermot Doherty

Funder/Sponsor

National Children's Research Centre

Keywords

Analgesia, Sedation, Paediatric, Intensive Care, Nursing, Change

Abstract

Background

International best practice endorses the use of a standardised approach in the management of analgesic and sedative drugs in the Paediatric Intensive Care Unit (PICU). In adult intensive care settings incorporating analgesia and sedation guidelines has been associated with significant patient benefits including a reduction in the amounts of analgesia and sedative drugs used and a decrease in the duration of mechanical ventilation.

In contrast, the evidence to support this change in practice in the paediatric setting is limited and inconsistent. Also the administration of analgesia and sedation has predominantly been based on personal preferences and ritualistic practice, without the support of an evidence base. The key role that PICU staff play in analgesia and sedation management, their perceptions around introducing changes in the management of analgesia and sedation has not been fully addressed. In an Irish context this study was seminal, as no previous studies had reported on current and alternate analgesia and sedation management practices within the PICU and the staff perception of a change of practice.

Research Hypotheses Given the lack of evidence in this area for PICU practice, this study aimed to address the following primary and secondary hypotheses:

Primary Hypothesis:

“Standardised pain and sedation management did not cause a reduction in the dosage of morphine administered to patients in PICU”

Secondary Hypothesis:

“The implementation of standardised pain and sedation was not associated with a change in duration of mechanical ventilation and PICU stay.”

Methods

Ethical approval was obtained for the study. A quasi-experimental approach was used employing a before/after design. Kotter’s model of change was chosen to guide the change intervention, which comprised the introduction of multidisciplinary developed analgesia and sedation guidelines in the PICU and standardised pain and distress assessment using the validated COMFORT-B instrument. Patient census data were retrieved from the PICU census database for 12 month time period before and after the change in practice. P1-The before group; consisted of all patients admitted to the PICU between 1st March 2009 and 28th February 2010, treated according to standard analgesia and sedation management practices. P2-The after group comprised all patients admitted to the PICU between 1st August 2010 and 31st July 2011. This patient group were managed according to the changed approach to analgesia and sedation management.

As census data are not conducive to deeper analysis, a subset of P1 and P2 was selected to facilitate more in-depth analysis. Strict inclusion and exclusion criteria were used to obtain 2 comparable groups. Using an instrument exclusively developed and validated for this purpose, the PASQ (Patient Analgesia and Sedation Questionnaire); data from these cardiac non-equivalent control (PASQ 1; n=61) and intervention (PASQ 2; n=64) patient groups were collected for the first 72h (3x 24 hour Epochs) post-operatively. In addition, staff surveys were conducted before and after guideline introduction using the SASQ (Staff Analgesia and Sedation Questionnaire) instrument. Chi-square analysis, t-tests and the Mann-Whitney-U test were used for group comparisons.

Results

The CIPP model of evaluation was employed to determine the impact of the change intervention, on both patients and staff. Before and after comparisons of study groups determined that:

Patient Census Data:

There was no statistically significant difference in the median duration of mechanical ventilation (3 days [2:7]) (p=0.44) or median length of PICU stay (4 days [2:8]) (p= p=0.47) between the before and after intervention groups P1 and P2. However, patients with Down Syndrome (Trisomy 21or T21) were noted to have a longer median duration of mechanical ventilation than non-T21 patients, which proved to be statistically significant (4 [2:9]) vs (3[2:7]), (p=0.017) and a significantly longer duration of PICU stay (6 [3:12]) vs 4 [2:8]), (p

After the intervention, the duration of mechanical ventilation for patients with T21 was reduced by one day (P1 4[2:9] vs P2 3[2:6], p=0.04). No statistically significant reduction in length of PICU stay emerged for this group (P1 6 [3:12] vs P2 5 [3:9], p=0.09). After the intervention, the duration of mechanical ventilation between T21 and non-T21 patients was comparable 3[2:7] and 3[2:6] (p=0.36) respectively, as was the duration of PICU stay for both T21 and non-T21 patient groups (5[3:9] vs 4[2:8]) (p=0.28) respectively.

PASQ Data:

No statistically significant reduction in morphine administration by continuous intravenous infusion emerged after the intervention in either of the 3 Epochs (Epoch 1 PASQ 1 median 36mcg/kg/hr [27.7:43.9] vs PASQ 2 median 27.4mcg/kg/hr [29.0:37.1] (p=0.13)). However, after the change in practice a statistically significant reduction the mean rate of morphine infusion on return to PICU from the operating theatre was noted (PASQ 1 69.5mkg/kg/hr vs PASQ 2 55.38mkg/kg/hr (p=

SASQ

A statistically significant increase in PICU staff satisfaction with analgesia and sedation practice after the intervention emerged (p

Conclusion

This study reports how a change in analgesia and sedation management in line with best international practice has been successfully implemented. There are considerable potential patient benefits of basing analgesia and sedation management on robust assessment using validated tools. The resulting statistically significant reduction in duration of mechanical ventilation in the T21 population has the potential to reduce exposure to the complications of mechanical ventilation and hospital acquired infections, as well as decreasing interruptions to cognitive and social development and the parental bonding process. Reduced resource usage has significant cost implications and can facilitate increased patient turnover at a time when hospital resources are limited and inpatient waiting lists exist.

An observed change in the pattern of analgesia and sedatives administered to patients in line with emerging evidence is welcome; acknowledging the risks associated with prolonged use of analgesia and sedation including withdrawal syndrome, and emerging evidence associating neuroapoptosis with use of certain sedatives. Using validated methods of assessing pain and distress leads to improved management which fulfils our humanitarian obligations and may increase job satisfaction. The neighbouring PICU has adopted the same approach to pain and sedation as it is seen best practice, moving towards standardisation at a National level. Valuable research collaborations have also evolved from the writers’ study and an important pharmacokinetic and pharmacodynamic study has been possible at the study site as a result of the implementation of validated pain assessment. High level dialogue about pain and sedation now occurs between clinicians and nurses, where previously uncertainty and a lack of direction prevented this from occurring.

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Comments

A thesis submitted for the degree of Doctor of Philosophy from the Royal College of Surgeons in Ireland in 2014.

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