(1214) Reducing the Percentage of Intubation Time on Continuous-Infusion Midazolam

Introduction: The 2018 Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the Intensive Care Unit guidelines recommended targeting a light level of sedation, prioritizing analgosedation, and avoiding benzodiazepine (BZD) sedatives. Previous studies have found increased delirium-free days and better compliance with the targeted sedation level with alternative agents. Despite this, many patients continue to be given continuous infusion (CI) BZDs following intubation. In critically ill patients, metabolites can accumulate leading to over sedation, prolonged ventilation, and delirium.

Methods: This was a quality improvement study conducted at a comprehensive cancer center. Pre-intervention and post-intervention data collection occurred between January 1, 2022 and October 31, 2022 and March 7, 2023 and May 5, 2023, respectively. Sedation was assessed utilizing the Richmond Agitation and Sedation Scale (RASS) and delirium using the Intensive Care Delirium Screening Checklist. Pharmacists, physicians, advanced practice providers, and nurses generated a sedation algorithm for mechanically ventilated (MV) patients. The algorithm prioritized analgesics, non-BZD sedatives, and intermittent BZDs. If CI midazolam was ordered, a 4-hour time-out was recommended to reassess for need. Education was provided to key stakeholders. The primary outcome was to reduce the percentage of intubated time that patients received CI midazolam by 30% by May 5th, 2023. Secondary outcomes included reducing the percentage of RASS outside the targeted range and the percent of inappropriate titrations.

Results: Sixty-one patients were included, with 43 in the pre-intervention group and 18 in the post-intervention group. The percent of intubation time on CI midazolam decreased from 74% to 58% (P=0.545). The time within the intended RASS range improved by 23% (P=0.232) and was driven primarily by reducing the percent of RASS scores < -1. The percentage of inappropriate titration was reduced from 30% from 22%.

Conclusions: This interdisciplinary algorithm aided in reducing the percentage of time MV patients received CI midazolam, improved adherence to the order-set, and reduced the percent of RASS scores outside the target range. Ongoing efforts should be directed at continuing to provide education.