Optimization of sedation management in pediatric cardiac intensive care: Implementation of a daily ordered State Behavioral Scale goal
By Julianna Boydston, RN, MSN, CCRN
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. Sedation management in critically ill pediatric cardiac surgery patients is imperative to promoting post-operative hemodynamic stability 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. This small test of change took place on a 12-bed high acuity Pediatric Cardiac Intensive Care Unit in a quaternary children’s hospital within a larger medical center.
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 completed to obtain a baseline data set of sedation management practices. 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 SBS assessment knowledge. A daily ordered sedation goal was implemented for every post-operative mechanically ventilated patient. Along with this intervention, multiple approaches for staff education were launched: documentation protocol review, demonstration of proper SBS assessment techniques, and distribution of tip sheets to prompt proper documentation, communication and assessment. Post-implementation data was collected one month after the intervention in the same manner as baseline data collection. There were a total of three post-implementation data collection periods to evaluate project sustainability.
The audit of multidisciplinary rounds showed an overall increase in multidisciplinary rounds discussion of sedation goals and plans. 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 periods. There was a substantial increase in staff knowledge after education was provided during the implementation phase of the trial, but this tapered with 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 project adds to the growing body of evidence suggesting that a targeted sedation goal may lead to improved patient outcomes. 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
Use of a standardized tool to assess the sedation needs of these patients promotes communication between members of the multidisciplinary team. Continued education and reinforcement of such tools are necessary for sustainability. 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.