Nursing Guidelines for Sedation Titration or Pausing to Facilitate Neurological Assessment.

Abstract

Q Per The Joint Commission, we need clearer nursing titration/pausing guidelines to facilitate serial neurological assessments. How can we titrate or pause sedation/analgesia infusions to facilitate serial neurological assessments as well as “standard” wake-up assessments in a way that is compliant with regulatory agencies?A Richard Arbour, MSN, RN, CCRN, CNRN, CCNS, CCTC, replies:The Joint Commission (TJC) overview of sedation, analgesia, restraints, and other practices has added additional requirements to documentation, policies, and clinical review as a means to increase standardization of care and, most importantly, patient safety. In particular, TJC has closely evaluated sedation/analgesia dosing and titration.Optimal, goal-directed sedation practices are well established and include 4 components. First, validated clinical assessment tools such as the Sedation-Agitation Scale and the Richmond Agitation-Sedation Scale (RASS) are used to determine therapeutic end points for patients who are not pharmacologically paralyzed.1–3 Second, targeted clinical end points for sedative/hypnotic agents are optimally aimed at “lighter” levels of sedation (eg, a RASS score of 0 to −2 [light sedation]),1 unless higher levels are clinically necessary; patients with these “lighter” levels of sedation are best described as calm and interactive and are able to respond appropriately to stimulation.2,4 Third, sedatives/hypnotic agents should be periodically interrupted or titrated down. This component has become well established since a landmark study in which Kress et al5 identified a connection between daily interruption of sedation and a shorter duration of mechanical ventilation; in current practice, meticulous patient selection and close monitoring are paramount to protect vulnerable patients from harm. Fourth, attention must be given to sedation and analgesic needs and to clinically appropriate nonpharmacological comfort measures, and treatable causes of agitation, pain, and delirium must be addressed.2–4To achieve optimal, goal-directed therapy, all 4 of these points need to be included in a plan of care. Previously, a team may have ordered a “wake-up assessment” for a patient, and that patient’s sedation/analgesic agents may have been abruptly stopped. From a regulatory perspective that assessment order may not have constituted a complete medication order. A complete medication order for titration includes the following items: Note that TJC allows for range orders and multiple range orders, so a provider can order titration increments for a range of times and doses. A direct care nurse would then apply their knowledge and experience with the patient to select the most appropriate interval and dose from among the ordered range when necessary.Clearer titration guidelines to facilitate serial neurological evaluation would include the required order elements and specifically attend to the desired clinical goal for wakefulness or responsiveness (eg, a RASS score of 0 to −1). In addition, downward titration of central nervous system depressants should be specified in institutional policy addressing titration, which should also include a specific callout for daily spontaneous awakening trials (SATs). One such example addressing regulatory considerations is outlined below.To the specific practice question, when considering an awakening trial for neurological assessment followed by specified baseline assessment and goals of care, optimal patient selection from among the neuroscience population is necessary to establish optimal risk/benefit analysis. Documentation should include baseline dosing for any central nervous system depressant, sedation depth, and repeat assessment after each dose change. When a patient’s sedation assessment identifies elements that remain outside the provider-ordered parameters, appropriate communication with the provider and documentation are indicated. If the order does not fit the clinical situation, contact the provider, clarify the order, and document.The importance of interdisciplinary collaboration cannot be overstated: it is essential in optimal patient selection for downward titration of sedation/analgesia to allow neurological evaluation. Respiratory therapy is integral when ventilator support is being titrated as an intervention to manage agitation or ventilator dyssynchrony. In addition to assessing patients and documenting, nurses implement nonpharmacological interventions, calm the patient and family, and facilitate a healing, caring environment. Pharmacy team members offer expertise in optimizing pharmacological therapies for managing pain and agitation. Physicians and advanced care providers are accountable for the overall plan of care and multisystem support. Of particular note is how practices such as sedation/analgesia titration and interruption continue to evolve on the basis of best available evidence and in collaboration with health care regulatory bodies. This collaboration has been useful in practice and in improving patient safety.