1430: NURSE-IMPLEMENTED SEDATION IN THE PICU IDENTIFYING OPPORTUNITIES FOR SLEEP PROTECTION

Abstract

Learning Objectives: Sleep in the PICU is poor and often fragmented due to sleep disruption caused by procedural interventions. Boluses of sedating medication may be given in nurse-implemented sedation protocols to counteract sleepdisrupting care; however these medications also disrupt sleep patterns. Sleep protecting protocols that limit non-essential procedures at night may improve sleep and limit sedation requirements. We hypothesized that there are opportunities to defer care and decrease sedation administration during night shifts. Methods: This is a cross-sectional study in healthy children admitted for bronchiolitis, intubated for more than four 12-hour shifts, who received protocolized sedation with fentanyl and midazolam from 1/2016-3/2018. Data on boluses of sedating medication and nurse-documented indications were extracted from the patient records. Boluses given for procedural reasons (PB) were categorized as being time-sensitive (TS) (PICC/PIV placement, respiratory treatment (RT), nasogastric tube placement, lab draw) and non-TS (endotracheal tube (ETT) tape change, weight/bath/linen (WBL) change, routine x-ray). We also identified disruptive routine cares such as position and diaper changes that may be limited, rather than deferred, at night. Results: There were 21 subjects and a total of 246 shifts during this study period, with an average of 4.28 (SD 3.11) boluses during day compared to 5.08 (SD 3.63) during night shifts (p=0.12). A total of 1618 sedation boluses were given, of which 758 (47%) were PBs, 671 (41%) were non-PBs, and 189 (12%) had no indication recorded. More total boluses occurred on night (57%) compared to day shifts (41%). PBs were also more prevalent on night shift (55%). Among 758 PBs, 32% had no documented indication. Of the remaining 514 PBs, 721 indications were documented. RT and routine care were the most common indications for PBs (30 and 37%, respectively). Overall, 73% of PBs given for non-TS indications were performed at night, which included 43% of ETT tape change, 93% of WBL changes, and 88% of routine x-rays. Routine cares were also cited as indications for PBs with equal frequency between day and night shifts. Conclusions: There is more procedural sedation at night compared to the day, and the majority of non-TS procedures occur at night. Routine care does not decrease in frequency at night. This study suggest there is opportunity to defer or limit nighttime nursing cares and procedures in order to minimize sleep disruptions and overall sedation needs.