Sedation stewardship: development of a national medication use evaluation for assessment of intensive care unit sedation practices during the covid-19 pandemic

SESSION TITLE: Education, Research, and Quality Improvement Posters 6 SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/11/2023 12:00 pm - 12:45 pm PURPOSE: Early data suggest that mechanically ventilated COVID-infected (COVID+) patients had increased sedation requirements compared with historical controls. The impact of these sedation practices on patient-relevant clinical outcomes remains unknown. To evaluate this concern for increased sedative use, we conducted a quality improvement medication use evaluation (MUE) project to assess sedation practice patterns and observed outcomes for mechanically ventilated COVID+ Veterans in intensive care units (ICUs). Our results are from pilot chart review. METHODS: A multidisciplinary team comprised of senior VA Center for Medication Safety (VAMedSAFE) staff, critical care providers, clinical pharmacists, and statisticians collaborated on the design of this MUE to measure sedation practices and clinical outcomes during the COVID pandemic across the Veterans Health Administration. A total of 13 VA medical centers (VAMCs) completed data use agreements to conduct local chart reviews. Given potential practice variations over the course of the pandemic, three time periods were selected for review: pre-(3/2019-2/2020), COVID Year 1 (3/2020–2/2021), and COVID Year 2 (3/2021–3/2022). Each participating VAMC will screen at least 75 patients from each of the 3 time periods from their site (anticipated total patient charts screened n=2925). Any ICU patient intubated for ≥2 calendar days will be eligible for analysis. Patients transferred from a non-VA facility, transferred out of the ICU within 48 hours of admission, or those intubated for >14 days will be excluded. Our primary outcomes include dose and duration of sedative exposure, hospital length of stay (LOS), new antipsychotic prescription, ileus, delirium, and overall mortality. Outcomes and covariates will be ascertained by structured data, when available, and validated by chart review. The MUE pilot was conducted from 1/2023-3/2023. RESULTS: The pilot identified challenges in operationalizing definitions for chart review. Among 83 patients from 11 participating sites, 49% met inclusion criteria. Most exclusions were due to ICU LOS restrictions in the initial MUE chart abstraction tool. As a result, we adapted the existing tool to restrict by intubation days >14 (vs. total ICU LOS). Our pilot also revealed wide variation in clinical pain assessment and spontaneous awakening trials. To maximize fidelity of these domains, we adapted the MUE to allow for open-ended and semi-structured responses. CONCLUSIONS: The MUE may inform opportunities to develop system-level medication use improvements at VAMCs. Understanding sedation use during high volume pandemic periods may also mitigate the strain from drug shortages in future respiratory pandemics. CLINICAL IMPLICATIONS: Formal assessment of prescribing practices and patient-relevant clinical outcomes via this MUE will help to guide creation and implementation of safer sedation guidelines within the VA healthcare system. DISCLOSURES: No relevant relationships by Kathleen Akgun No relevant relationships by Kelly Bryan No relevant relationships by Kenneth Bukowski No relevant relationships by Muriel Burk No disclosure on file for Fran Cunningham No relevant relationships by BreAnna Davids No relevant relationships by Trisha Exline No relevant relationships by Brooke Klenosky No relevant relationships by Jennifer Lee No relevant relationships by Kathleen Morneau No relevant relationships by Ian Murphy No relevant relationships by Sarah Providence No relevant relationships by Lauren Ratliff No relevant relationships by Stacey Rice No relevant relationships by Elizabeth Rightnour No relevant relationships by Abbie Rosen No relevant relationships by Travis Schmitt No relevant relationships by Ann-Marie Sutherland No relevant relationships by Preston Witcher No relevant relationships by Mark Wong No relevant relationships by Sarah Zavala