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Organizational factors associated with target sedation on the first 48 h of mechanical ventilation: an analysis of checklist-ICU database

Critical Care. 2019;23(1):1-8 DOI 10.1186/s13054-019-2323-y

 

Journal Homepage

Journal Title: Critical Care

ISSN: 1364-8535 (Print); 1466-609X (Online)

Publisher: BMC

LCC Subject Category: Medicine: Internal medicine: Medical emergencies. Critical care. Intensive care. First aid

Country of publisher: United Kingdom

Language of fulltext: English

Full-text formats available: PDF, HTML

 

AUTHORS


Antonio Paulo Nassar (Intensive Care Unit and Postgraduate Program, A.C. Camargo Cancer Center)

Fernando G. Zampieri (Research Institute, HCor-Hospital do Coração)

Jorge I. Salluh (Graduate Program in Translational Medicine and Department of Critical Care, D’Or Institute for Research and Education)

Fernando A. Bozza (Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (FIOCRUZ), Instituto D’Or de Pesquisa e Ensino (IDOR))

Flávia Ribeiro Machado (Anesthesiology, Pain and Intensive Care Department, Federal University of São Paulo)

Helio Penna Guimarães (Research Institute, HCor-Hospital do Coração)

Lucas P. Damiani (Research Institute, HCor-Hospital do Coração)

Alexandre Biasi Cavalcanti (Research Institute, HCor-Hospital do Coração)

EDITORIAL INFORMATION

Blind peer review

Editorial Board

Instructions for authors

Time From Submission to Publication: 14 weeks

 

Abstract | Full Text

Abstract Background Although light sedation levels are associated with several beneficial outcomes for critically ill patients on mechanical ventilation, the majority of patients are still deeply sedated. Organizational factors may play a role on adherence to light sedation levels. We aimed to identify organizational factors associated with a moderate to light sedation target on the first 48 h of mechanical ventilation, as well as the association between early achievement of within-target sedation and mortality. Methods This study is a secondary analysis of a multicenter two-phase study (prospective cohort followed by a cluster-randomized controlled trial) performed in 118 Brazilian ICUs. We included all critically ill patients who were on mechanical ventilation 48 h after ICU admission. A moderate to light level of sedation or being alert and calm (i.e., the Richmond Agitation-Sedation Scale of − 3 to 0) was the target for all patients on mechanical ventilation during the study period. We collected data on the type of hospital (public, private, profit and private, nonprofit), hospital teaching status, nursing and physician staffing, and presence of sedation, analgesia, and weaning protocols. We used multivariate random-effects regression with ICU and study phase as random-effects and correction for patients’ Simplified Acute Physiology Score 3 and Sequential Organ Failure Assessment. We also performed a mediation analysis to explore whether sedation level was just a mediator of the association between organizational factors and mortality. Results We included 5719 patients. Only 1710 (29.9%) were on target sedation levels on day 2. Board-certified intensivists on the morning and afternoon shifts were associated with an adequate sedation level on day 2 (OR = 2.43; CI 95%, 1.09–5.38). Target sedation levels were associated with reduced hospital mortality (OR = 0.63; CI 95%, 0.55–0.72). Mediation analysis also suggested such an association, but did not suggest a relationship between the physician staffing model and hospital mortality. Conclusions Board-certified intensivists on morning and afternoon shifts were associated with an increased number of patients achieving lighter sedation goals. These findings reinforce the importance of organizational factors, such as intensivists’ presence, as a modifiable quality improvement target.