make improvements - Satya Pal Singh ST2 BACKGROUND Many sedation scores available Due to concerns regarding over and under sedation in ICU To titrate sedation to optimum level for the patient Objective means of assessment UHNM uses RASS Score METHODOLOGY Retrospective study to look into target RASS prescription RASS assessment whether the change in RASS was actioned by a change in sedative infusion rates Randomly assessed 30 ITU patients charts at different times Also looked into the awareness about RASS score among the nursing staff RESULTS Audit of 30 ITU charts RASS score target prescribed : 8/30 RASS scoring done daytime 2 hrly : 10/30 RASS scoring done night 4 hrly : 13/30 Change in RASS actioned : 3/5 Could tell how RASS is calculated : 18/30 DISCUSSION RASS target prescribed : 27% RASS scoring done daytime: 33% RASS scoring done nighttime: 43% Change in RASS actioned: 60% Awareness about RASS: 60% INDICATIONS FOR SEDATION & ANALGESIA tolerance of endotracheal tube and IPPV tolerance of invasive monitoring (insertion) tolerance of interventions e.g. suctioning, prone positioning relief of psychological distress analgesia post-operatively or post-trauma relief of agitation reduction in raised intracranial pressure/ prevention of surges in ICP reduction in oxygen demand and oxygen consumption simulation of sleep wake cycles EFFECTS OF INADEQUATE SEDATION/ ANALGESIA agitation and confusion inadvertent removal of invasive monitoring inadvertent removal of endotracheal tube ventilator dysynchrony rises in ICP CVS instability Increased O2 demand Post traumatic stress disorder Sympathetic activation (tachycardias, hypertension, tachypnoea) Poor pain control Adverse physiological responses (hypercoagulability, immunosupression) EFFECTS OF EXCESSIVE SEDATION/ ANALGESIA Prolonged weaning from ventilator and increased LOS on ICU Inadequate cough / clearance of secretions Increased exposure to side effects (e.g. hypotension, bradycardia, increased lipid loads) Difficulty assessing neurological function or changes in status Risk factor for ventilator associated pneumonia Post ICU psychological stress (related to prolonged amnesia) RESULTS Audit of 30 ITU charts RASS score target prescribed : 8/30 (27%) RASS scoring done daytime 2 hrly : 10/30 (33%) RASS scoring done night 4 hrly : 13/30 (43%) Change in RASS actioned : 3/5 (60%) Could tell how RASS is calculated : 18/30 (60%) CAUSE/DEFICIENCIES Doctors Target RASS prescription What target to prescribe?- no specific guideline Nurses Awareness- Being addressed by Rehab Team Commitment- addressed after introduction of Centricity On-line RECOMMENDATIONS RASS Calculation in all ITU patients Daytime 2 hrly, night 4 hrly, and PRN Prescribe Target RASS in all ITU patients ACTION PLAN Recommending changes as to how frequently the RASS scoring should be done (the Trust ICM guidelines are lacking in this aspect) Teaching sessions for the Doctors Information to new doctors on Induction FOLLOW-UP Re-audit in 2 months after implementation of action plan