Problem/Significance

Among patients who are mechanically ventilated, discomfort associated with the endotracheal tube and other devices requires routine administration of analgesics and anxiety-relieving medications. Existing guidelines address the practice of sedative administration, however, there has not been wholesale adoption of this practice, and thus actual clinical practice is variable. In addition, the practice of "daily wakeup"- a procedure for withholding sedative medications until the patient can follow commands, becomes agitated, or is objectively uncomfortable - has been described as a necessary safeguard against oversedation. This practice is potentially harmful and clinical outcomes demonstrate that standardizing sedative medication use and eliminating "wakeup" is superior to outcomes published in the literature where the daily wakeup is used.

Purpose

This project aimed to create a standardized protocol for medication management of discomfort among ventilated patients in an ICU setting.

Description of Project

Physicians, nurses, and pharmacists designed and implemented a sedation scale and protocol that empowered nurses to meet therapeutic goals for anxiety management while eliminating the occurrence of oversedation.

Methods

The critical care CNS of this Midwestern integrated health network led a multidisciplinary team to implement evidence- based interventions to improve the practice of the administration of anxiety-relieving medications. The team standardized drug selection and administration guidelines- using a scale and protocol. The team effectively worked to change the language (and thinking) to "anxiety-relieving medications" from the old term "sedatives."

Outcomes

This protocol has been successfully implemented in 3 ICUs within this integrated network. The outcomes associated with nurses using the standardized guidelines included decreases in length of stay, incidences of ventilator-associated pneumonia (VAP) cost per day, and mortality.

Conclusions/Nursing Implications

The outcomes in this health care network demonstrate that the practice of managing the anxiety among ventilated ICU patients can be accomplished by use of a specific, standardized protocol developed by a multidisciplinary team and implemented by staff nurses. The practice of the daily wakeup is not necessary if the staff is educated and empowered to manage the anxiety of the patients.

Section Description

This year's annual NACNS conference is planned for Orlando, Fla, March 9-12, 2005. Over 300 clinical nurse specialists (CNSs) are expected to attend, and as with past conferences, attendees will also include graduate faculty from CNS programs, nurse administrators, and nurse researchers. The theme of the conference, CNS Leadership: Navigating the Healthcare Environment Toward Excellence, was selected to showcase the many ways CNSs acquire and disseminate knowledge and innovative practices in their specialty areas. Two preconference sessions are scheduled. One session, sponsored by NACNS Legislative/Regulatory Committee, targets information for CNSs interested in understanding the legislative/regulatory process as it deals with the practice of nursing, and will also help build skills CNSs need to engage in the process. The second session, sponsored by NACNS Education Committee, focuses on CNS education issues, and as with the education preconferences of past years, anticipates informative dialogue and much sharing among CNS educators around curriculum design, teaching strategies, and indicators of quality in the curriculum that link to the NACNS education standards to program review and excellence. The conference planning committee is proud and pleased to have Jeanette Ives Erickson, MS, RN, CNA, Senior Vice President for Patient Care Services and Chief Nurse Executive of Massachusetts General Hospital as the opening keynote speaker. She will begin the conference by highlighting the importance of CNS practice on patient safety. The planning committee is equally proud and pleased to have NACNS past-president Rhonda Scott, PhD, RN, Chief Nursing Officer of Grady Health System as the closing speaker. Dr Scott will challenge attendees to use the information from the conference to shape quality care delivered in a safe environment and to advance the profession of nursing through direct care to clients, influencing standards of care delivered by other nurses, and influencing the healthcare delivery system to be to support innovative, cost-effective, quality nursing care. A total of 64 abstracts for podium and poster presentations were selected in addition to graduate student posters. The abstracts address the 3 spheres of CNS practice with a strong emphasis on clinical practice improvements. As you will note from the abstracts published in this issue of the journal, specialty practice areas represented in the abstracts include children, adults, and gerontological patient groups; hospital, outpatient, and home care settings, and community health. In addition, a wide variety of specialty topics including smoking cessation programs, end-of-life care issues, and protocols outlining nursing approaches to improved diabetes, cardiovascular and ventilator management. A number of the abstracts described hospital and healthcare system level innovations that resulted from CNS practice. Collectively, these abstracts reflect the breadth, depth, and richness of CNS contributions to the well-being of individuals, families, groups, and communities. The following abstracts are from those presenters who elected to have their work published in the journal so those who are unable to attend this year's conference can share in the knowledge of the conference. As you read each abstract, consider the talent and clinical scholarship of your CNS colleagues who are advancing the practice of nursing and contributing to improved outcomes for patients and healthcare organizations. You may want to contact individual presenters to network, collaborate, consult, or share your own ideas about these topics. Watch for next year's call for abstracts and consider submitting an abstract for presentation at NACNS's next conference in Salt Lake City, Utah, March 15-18, 2006.