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Evidence Based Practice Proposal (EBPP)
Kara Elkins
Ferris State University
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Article annotation 1
Cutugno, C. (2007). Sedation in Mechanically Ventilated Patients. American Journal of Nursing, vol.107,
issue 11, 72AA. doi: 10.1097/01.NAJ.0000298070.42596.0b
Christine Cutugno is an assistant professor at Hunter University School of Nursing. She has her PhD in
nursing and is also CCRN certified. This article aims to show that even though the goal for ventilated
patients is as little sedation as possible, these patients still require minimal sedation to reduce stress and
anxiety due to invasive and life saving devices. Christine says that using a universal sedation assessment
tool is extremely important so that the nurses and all Drs. are consistent in giving their patients sedation
medication. She also points out the difference of judgment when it comes to assessing a patient
between varying nurses, and this is another reason why using an easy, universal assessment tool is
crucial.
Article annotation 2
Pun, B.T, Dunn, J. (2007). The Sedation of Critically Ill Adults: Part 2: Management. American Journal of
Nursing, vol. 107, issue 8, 40-49. doi: 10.1097/01.NAJ.0000282293.72946.1f
Brenda Punn, MSN,RN,ACNP is a project manager at Vanderbuilt Univeristy Medical Center and is a
member of its ICU Delirium and Cognitive Impairment Study Group. Jan Dunn MSN, RN is a research
coordinator at Saint Thomas Hospital and also works for Hospira (manufacturer of certain sedation
medications). This article shows that under sedation is just as harmful for ventilated patients as over
sedation. They say that without having agreed upon sedation goals between Drs. and nurses there is a
risk of complications regarding over or under sedation which could possibly impede recovery. The
recommended medication for long term sedation is Propofol because of its short half-life. This drug
allows daily awakening trials without much discomfort for the patient. Versed, Ativan, Haldol, and
Fentanyl are recommended more for rapid sedation of extremely agitated patients. Picking the
appropriate drug for patients is important along with trialing non-pharmacological techniques first such
as low stimulation guidelines. This article is written by an employee of a drug manufacturing company
and may be biased.
Article annotation 3
Jackson, D.L. , Proudfoot, C.W , Cann, K.F., Walsh, T. (2010). A Systematic Review of the Impact of
Sedation Practice in the ICU on Resource Use, Costs, and Patient Safety. Critical Care, vol.14,
issue 2, 59. doi: 10.1186/cc8956
Timothy Walsh is a Professor of Anesthetics and Critical Care at Edinburgh University. Daniel Jackson is
Head of Health Economics, EMEA at GE Healthcare. Clare Proudfoot is a Consultant at Heron Evidence
Development Ltd, a health outcomes research consultancy. Kimberley Cann is a Health Outcomes
Analyst at Heron Evidence Development Ltd. This article is a research experiment that shows that there
is strong evidence supporting sedation improvement of ventilated patients and reduced length of
ventilation and ICU stay. This article supports daily sedation breaks to perform spontaneous breathing
trials (SBTs), crucial for weaning vent support. These authors also state that adequate sedation of these
patients could not only benefit the patients with better control of pain and anxiety, but improve health
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care costs because of shortened hospital stays and lengths of time on life saving invasive devices. Their
research determined the use of specific protocols was influential in giving the patients the amount of
sedation needed without giving too little or too much.
Evidence of Reasoning Proposal (EOP)
The problem that I am hoping to address is the inconsistency of following sedation protocols, and
sedation assessments between nurses and Drs.
Purpose: Appropriate sedation measures keep our patients at a lower risk for anxiety issues and in long
term a lower risk for ICU psychosis. It also keeps our patients from experiencing the pain and discomfort
of invasive life support devices such as mechanical ventilation by endotracheal tubes (ET tubes).
Questions: Why do we use protocols with so much leeway on sedation goals? Why are Drs. shying
away from sedating our ventilated patients even when they are extremely anxious? How can we help
family members understand the importance of minimal stimulation for their loved one?
Point of View: When taking care of these critically ill patients I see all kinds of unnecessary stimulation
that results in extreme anxiety and increase in respiration and blood pressure for my patients. We have
simple rules to minimize this stimulation such as 1-2 visitors in the room at a time, dim lights, lights out
with no television or radio at night, and low volume on the monitors. I also see vented patients who are
anxious and need to be restrained to prevent extubation or removal of important lines who aren’t
sedated. Why do Drs. feel that these patients are ok without any type of anxiety medication even after
we try non-pharmacological techniques first? These patients are suffering from unnecessary
discomfort.
Information: Many things contribute to anxiety and eventually ICU psychosis. Some of these things
cannot be helped in the ICU setting, but some can. Things that can be fixed are adequate sedation,
minimizing noise in the patient’s room, and limiting family noise. Family members are an important part
of the healing process, but too much can be detrimental to the patient’s health. Mechanical ventilation
and invasive lines and procedures are extremely painful, and restraining patients is very uncomfortable.
We have a policy that all ventilated patients need to be restrained to prevent extubation, but where is
the policy for appropriate sedation for these patients?
Concepts and Ideas: We need to be using the types of sedation that even when used long term are easy
to come off of such as Propofol or Precedex instead of the use of large doses of narcotics and
benzodiazepines. This way it will be out of the patient’s system faster and shouldn’t decrease chance of
getting off ventilator support. When the patient is admitted the family needs to know the rules of the
ICU to keep their loved one safe, and we as staff need to enforce these rules consistently to protect the
wellbeing of our patients. We need to develop a better assessment tool and protocol for when to
sedate a patient, and it needs to be agreed upon by nurses and Drs. so that we all can stay consistent.
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Assumptions: There will always be those tough family members who will fight until they get what they
want, and no one will stand up to them to enforce the rules, or the Drs. who will refuse to give the
patient any sedation regardless of the patient’s anxiety level. Being a teaching hospital we constantly
have new Interns and Residents caring for these patients, and not all of them have the same point of
view in sedation techniques. Nothing will be perfect, we just need to strive to do our best for our
patients.
Implications and Consequences: I think we all know what the consequences will be. Worse case our
patients could ultimately suffer from PTSD or ICU psychosis. This will lengthen the hospital stay or at the
very least be a huge setback for the patient and their family with possibly years of symptoms related to
their experience. Our patients could have anxiety attacks, blood pressures could spike resulting in other
health problems, or their respirations could become rapid resulting in blood gasses that need to be
normalized.
Inference and Interpretation: We, as a unit, need to do something as a team to help our patients so
they aren’t at an increased risk for these problems. We also need to collaborate with our physicians so
that we are all on the same page regarding sedation for our patients. Our attending physicians need to
teach our sedation protocols to all new Interns and Residents coming in to the program so that sedation
can remain consistent regardless of new Drs. moving in and out of the unit.