Current practices and barriers impairing physicians’ and nurses’ adherence to analgo-sedation recommendations in the intensive care unit - a national survey

Minimization of sedatives is recognized as the cornerstone of sedation management in ICUs, and strategies targeting light sedation – including assessment using validated scales, protocolization and daily sedation interruption (DSI) – are associated with improved patient outcomes [1]-[4]. However, which strategy is safest or most efficient is still a subject of debate, so the choice of management depends on the context and potential barriers identified locally [1],[5],[6]. Similarly, appropriate pain assessment and management is associated with important patient benefits [7],[8]. Despite support from various guidelines to assist clinicians in implementing these practices in ICUs, the use of such strategies varies internationally and shows substantial room for improvement [1],[9]-[11]. Furthermore, observational studies have shown that nearly one-half of ICU patients are deeply sedated [12],[13].

Research looking specifically at factors influencing practices in the field of analgo-sedation in the ICU is limited [14]-[21]. Some studies were qualitative in nature, limiting generalizability of results [18]-[20]. Quality improvement projects have provided valuable information on how to improve practices; unfortunately these studies were typically monocentric or conducted in a limited number of centers, thereby also reducing generalizability [22]-[26]. Finally, the body of evidence has come exclusively from North America; the European perspective, with its own barriers and enablers, has not been explored.

Implementing analgo-sedation strategies requires daily commitment and strong collaboration of all clinicians involved, especially nurses and physicians. Lack of shared understanding regarding these practices is present within ICU teams [13],[14],[18],[20]. We have conducted a qualitative study suggesting that profession is a key factor in influencing adherence to analgo-sedation recommendations [20]. ‬Previous research has mostly focused on the physician’s or the multidisciplinary team’s perspectives [11],[14],[15],[17],[27]. The nursing’s perspectives were underrepresented in multidisciplinary surveys to assess heterogeneity between professions. Identifying barriers for physicians and nurses separately and specifically is essential to design interventions for improvement, tailored to each profession.

Our first objective was to describe reported utilization of: analgesics and sedatives; validated scales for pain assessment; validated scales for sedation assessment; protocolized analgo-sedation; and DSI. A second objective was to describe the presence of common perceptions enabling or challenging utilization of these strategies (more particularly assessment of sedation using validated scales and DSI) and compare these amongst physicians and nurses.

We conducted a nationwide survey on sedation and analgesia practices and their determinants in ICUs across Belgium.

Our data indicate poor compliance with analgo-sedation recommendations in terms of assessment of pain and sedation, protocolized sedation and DSI. We identified barriers potentially impairing adherence, with differences observed between physicians and nurses.

Despite recognized benefits, significant gaps in assessment of sedation and pain are present. Regarding pain assessment in patients unable to self-report, behavioral scales (Behavioral Pain Scale, Critical Care Pain Observation Tool) are scarcely available, leaving a vast majority (88%) of respondents relying only on behaviors and/or physiological parameters, even though the latter are unreliable pain surrogates [33],[34]. Sedation scales are widely adopted, as availability is similar to the highest frequencies reported in the international context [35],[36]. Unfortunately, the most valid and reliable scales (Sedation Agitation Scale, Richmond Agitation Sedation Scale) are available to only 27% of respondents [1]. Additionally, whether a daily frequency of use below three times a day, as indicated by 17% of respondents, is sufficient to impact patient outcomes is questionable [1]. Protocolized analgo-sedation, combining patient assessment and algorithms by which nurses adjust analgesics’ and sedatives’ dosages accordingly, has been associated with beneficial patient outcomes including reduced duration of mechanical ventilation [3]. We found that protocols are available to only one-third of respondents, comparing unfavorably with the highest rates of availability reported in the United Kingdom (80%) and the United States (71%) [35],[36]. Convenience sampling of the latter surveys may explain these results, as only clinicians highly involved in analgo-sedation practices may have responded. Because assessment is essential in providing the basis for the treatment of pain and agitation/anxiety, underuse of appropriate scales may lead to inappropriate treatment of pain and agitation. Also, the high availability of sedation scales in Belgian ICUs contrasts with the low adoption of protocolized sedation, potentially increasing treatment delays.

Perceptions challenging utilization of sedation scales are present, especially for nurses. For example, more nurses than physicians disagree that using a sedation scale may: increase nurses’ autonomy; enhance their role; or influence management beyond simple assessment, with an effect on physicians’ prescription or nurses’ administration of sedatives. These findings show that nurse empowerment has not been appropriately tackled in units where sedation scales are used. We hypothesize that a low availability of protocols clarifying nurses’ responsibilities as well as how to adapt dosages according to assessments may explain poor utilization of scales. More physicians than nurses agreed with statements reporting potential benefits of sedation scales (improve communication, consistency in sedation practices and help to monitor cost). However, although statistically significant, some of these differences between physicians and nurses are small and questionable of clinical relevance.

DSI is infrequently used in Belgium, despite substantial clinical benefits including reduced length of stay [2],[4]. Internationally, less than one-half of clinicians report using DSI [11],[37]-[39]. Our results contrast with those of a recent survey showing that one-half of the respondents reported regular use of DSI (defined as greater than 75% of mechanically ventilated patients) [21]. Highly motivated respondents may explain the latter results, as these were part of a statewide ICU quality improvement collaborative.

Perceptions challenging DSI are present for more nurses than physicians. Previous research showed lack of nursing acceptance is one of the three most common barriers to the practice [14]. Some of our findings may explain such reluctance. First, safety concerns are present for more nurses than physicians (perception that DSI increases the risk of complications such as device removal, impairs patient comfort and creates traumatic memories). These fears were reported previously, despite evidence demonstrating safety of DSI [14],[20],[21],[6],[40]-[42]. Accordingly, more nurses than physicians agree they would prefer not to have DSI if they were a patient. Second, more physicians than nurses find DSI is contraindicated in situations where sedation is used for reasons other than agitation (concomitant management with neuromuscular blocking agents, seizures and refractory intracranial hypertension). In contrast, more nurses than physicians find that situations frequently encountered in the ICU (hemodynamic instability, complicated weaning from mechanical ventilation and substance abuse) are contraindications to DSI, and therefore many patients may not benefit from this strategy. The perception that complicated weaning from mechanical ventilation is a contraindication to DSI is particularly worrisome because the process of discontinuing ventilator support is affected by sedative use. DSI facilitates extubation by increasing the likelihood that patients are neurologically ready for it, once respiratory failure has improved, and combination with spontaneous breathing trials, has improved 1-year survival in ICU patients [2]. Appropriateness of performing DSI in specific patients remains controversial, because the benefits of alcohol withdrawal or ongoing agitation remain uncertain and efficacy and/or safety have not yet been sufficiently demonstrated in surgical, trauma and neurologic patients [1],[5],[43]. Yet some contraindications to the practice are not subject to debate, such as concomitant use of neuromuscular blocking agents. However, only 66% of nurses and 85% of physicians report the latter as a contraindication to DSI, which reflects a concerning lack of knowledge. Interestingly, strategies successful in implementing DSI have used safety screens and failure criteria, ensuring empowerment of ICU staff, particularly nurses, to assess whether DSI may be safely performed in their patients [2],[23]. Also, favorable interdisciplinary communication with sedation goals discussed on rounds increases nurse’s willingness to perform DSI [17],[21]. Finally, perceptions including that an asleep patient is easier to take care of than an awake patient and that DSI use is limited by organizational constraints are also present for more nurses than physicians. Perceived impact on workload by nurses has been shown to be higher for DSI than protocolized sedation [5]. The perception that DSI is hard work was shown to be negatively associated with regular use [21]. Incentives may include the perspective that awake, alert, comfortable patients may actually be easier to take care of for various reasons. First, the risk of delirium may be reduced. Second, patients may communicate their needs to ICU staff and participate in their own care decisions, even though communication remains challenging. Education highlighting these incentives for nurses, and availability of appropriate tools to enhance communication with nonverbal patients (for example, communication boards, illustrations) may improve nurses’ acceptance of the practice.

Compliance with analgesia and sedation recommendations in Belgian ICUs is poor for assessment of analgesia and sedation and strategies used to target light sedation (DSI and protocolized sedation). Numerous misperceptions hinder compliance with these strategies. Frequency of agreement with such misperceptions is systematically higher for nurses than for physicians. Implementational strategies must include efficient nurse empowerment and protocolized care to garner buy-in from key stakeholders in pain and sedation scales, while education on safety and contraindications of DSI must be discussed and agreed upon in ICU teams.