Optimization of sedation management in pediatric cardiac intensive care: Implementation of a daily ordered State Behavioral Scale (SBS) goal
By Julianna Schmidt, RN
This small test of change took place on a high acuity Pediatric Cardiac Intensive Care Unit in a 12-bed urban tertiary children’s hospital within a larger medical center. Sedation management in this population is imperative to promoting hemodynamic stability after cardiac surgery and improving patient outcomes. The State Behavioral Scale (SBS) is a tool used to assess agitation in the mechanically ventilated patient. Implementation of a daily ordered SBS goal for post-operative patients was used to improve interdisciplinary communication regarding sedation, promoting clinical nurse documentation of the SBS score and increasing both medical and nursing staff knowledge of the SBS assessment tool.
Does the implementation of a daily ordered sedation goal for intubated patients following cardiac surgery promote documentation of the State Behavioral Scale (SBS), improve communication of sedation and increase staff knowledge of the SBS tool?
A pre-implementation data collection period was performed to obtain a baseline data set of sedation management practice. This included patient chart review to identify frequency of SBS documentation, an audit of multidisciplinary rounds to understand the regularity of sedation management goals and plans discussion and a staff survey to assess staff knowledge of the SBS assessment. A daily ordered sedation goal was implemented for every post-operative mechanically ventilated patient. Along with this intervention there was education of staff on protocol and proper SBS assessment techniques and tip sheets presented to prompt proper documentation, communication and assessment. Post-implementation data was collected one month after the initial introduction of the intervention in the same manner as previously discussed with the baseline data collection period. There were a total of three post-implementation data collection periods to promote sustainability of the project.
Three data collection periods were conducted after implementation of the daily ordered sedation goal. The audit of multidisciplinary rounds showed an overall increase with sedation goal discussed and sedation plan addressed during multidisciplinary rounds. An initial improvement of SBS documentation was observed with the first post-implementation data collection period, however there was a slow decline in the second and third post data collection periods. There was a substantial increase in staff knowledge after education was done during the implementation phase of the trial but this too tapered with the successive post-implementation data collection periods. These declines in compliance suggest the importance of continued education and reinforcement for the overall sustainability of the project.
This small test of change adds to the growing body of evidence in literature to suggest that a targeted sedation goal can lead to improved patient outcomes in a variety of patient populations. Utilizing a targeted sedation goal promotes effective communication between members of the multidisciplinary team ensuring all members agree on the sedation pathway after cardiac surgery. Pediatric patients with congenital heart defects are one of the most vulnerable populations and require specific sedation levels to maintain hemodynamic stability following cardiac surgery. Use of a standardized assessment tool allows staff to effectively assess and communicate the sedation needs of these tenuous patients.
This study identified the efficacy of a daily order sedation goal for pediatric patients following cardiac surgery requiring mechanical ventilation. Use of a standardized tool to assess the sedation needs of these patients promotes communication between members of the multidisciplinary team. This project was an initial beginning to the development of a sedation protocol to be used for this patient population. Education of the staff to increase their knowledge of the SBS assessment and document was an important building block for the implementation of a sedation protocol. Continued small tests of change are needed to sustain the progression of sedation management in pediatric patients follow cardiac surgery.