sedation protocol mechanically ventilated patient

gizelda196 · Dec 9, 2005

The nurses in my hospital always write the policies One is usually chosen and then she "recruits" help from her peers. committees are formed . It is very rewarding in that hospitals are nurse run and who better to write new policies then the nurses who are there doing it. Mds should not be writing nurse policies nor should administrators it should come from the bedside . Like someone else said use evidence based research and make up tools like polls and questionnaires to start like "In your practice how have you found it to get sedation orders from and MD at 3am While your vented pt is sitting bolt upright in restraints?" Something like this would track a need to have standard sedation orders that could be activated on admission to the unit and co signed by an md in the am. Most of our pts start with what we call 2&2 (2mg versed 2 mg mso4) Q1hr prn. This works well until the pulmonologist makes it in in the am . But ods and etohs really should just be propofoled so shouldn't pts one certain types of ventilation where if they even moved a finger they could have a lung blown out. All these factors need to be taken into consideration. Oh and don't forget the 80 year old woman who is intubated a hundred times and is a pro and requires no sedation. you could gear it for like a clinical pathway if this is the alertness level give this. I think the lovely JACHO is even screwing with how orders are written and meds are given now like One perc for pain 1-4 and two percs fro pain 5-6 and they have to be clearly written like that So no more tit rate to sedation I cant wait to see how this is going to fly! Imangine trying to gear the pt on levophed, neo and propofol with jacho 's idea of things. geez but this is another topic. gather all the info and go from there good luck

RNforLongTime · Dec 10, 2005

We use the RASS scale in my 28 bed Surgical/Trauma/Cardiac ICU. Usually we use Diprivan for sedation of mechanically ventilated pt's. Sometimes ativan. We use Fentanyl as well. Our Intensivists and the PharmD developed our sedation/analgesia protocol. We've run Diprivan up to 125 mcgs. Beware of Propofol infusion syndrome.

As a nurse, I wouldn't be comfortable developing this kind of a policy, the MD Director of your ICU should develop such a protocol with input from nursing staff. Good luck!

dfk, RN, CRNA · Dec 10, 2005

i don't understand why. the pharm doesn't know what goes on, especially throughout the night... the nurses are the ones whom carry everything out, even suggestive when the pgy's are unsure, which happens quite frequently. basically, if the nurse wants to take on the responsibility, should it be their drive, then so be it. we, as nurses are the ones around all the time. credit should lay where it deserves.. besides, who else is gonna do this diryt work?

rookreck · Dec 10, 2005

I think if I worked in a large institution that a physician or an intensivist would be given the task of writing the protocol. I don't know if any of you have worked in a small facility. I work in a 120 bed hospital. We have one 8 bed intensive care unit. We have no residents and no intensivist. So we dont' have all the resources of a large facility. That is why many times staff nurses develop the protocols and policies. Physicians always review and critque them and have the final approval. I used to work in a large facility and it is totally different. In a small facility, when you have a bad patient the attending physician at home has to rely on the nurses assessment skills and judgement. In a large facility, you have the residents to fall back on . Although that isn't always a huge help. I think what I am trying to say, is that small facilities have to use the nurses as resources, since they don't have as many physicians.

dfk, RN, CRNA · Dec 10, 2005

ok rookreck, i hear ya. i worked in a 100 bed facility with an 8bed icu as well.. it is a different type of responsibility. i actually had less freedom than i do now at a larger teaching facility. couldn't even hang a liter w/o the "ok" from the critical care, gi, or whatever doc. must've been a power thing, or trust.. although, some are trusted and can have some leeway. (btw, i would hang if necessary, and i don't care what any doc says.. pt first! besides, i haven't met anybody who couldn't use a little LR or NS??) nurses are the tools that fine tune protocols as such, so why not be the frontline?

zambezi, BSN, RN · Dec 10, 2005

Our clinical nurse specialist and policy committee (staff nurses that have been chosen or voluenteered) write our protocols and policies...

These protocols are then reviewed by the lead pharmacist and by the ICU/CICU medical directors and/or by the docs that will be utilizing it (ie: the cardiac surgeons). Once everyone has reviewed and okays it, it becomes policy. Our ICU/CICU medical directors review almost all of the policies after they are written by the nursing staff and CNS...

I think that our physicians prefer it this way...we can shape it so it is acceptable to what we like as RNs and they review it for safety, medical effectiveness, etc...they don't want to spend their time writing policies that we implement and utilize- that said, they of course, order the protocls and have to know what they consist of...

candyndel · Dec 12, 2005

I cant even believe what I am hearing (seeing?) on this post.

Do some of you really believe that a Nursing Policy shouldnt be written by a nurse?

This is a nurse-driven, collaborative effort and she seems to have the right team together.

I think if I worked in a large institution that a physician or an intensivist would be given the task of writing the protocol. I don't know if any of you have worked in a small facility. I work in a 120 bed hospital. We have one 8 bed intensive care unit. We have no residents and no intensivist. So we dont' have all the resources of a large facility. That is why many times staff nurses develop the protocols and policies. Physicians always review and critque them and have the final approval. I used to work in a large facility and it is totally different. In a small facility, when you have a bad patient the attending physician at home has to rely on the nurses assessment skills and judgement. In a large facility, you have the residents to fall back on . Although that isn't always a huge help. I think what I am trying to say, is that small facilities have to use the nurses as resources, since they don't have as many physicians.

RNforLongTime · Dec 26, 2005

Candy,

Let me rephrase my original reply. I have no problem developing policies for generalized nursintg tasks. We do this all the time at my facility. Sedation protocols involve MEDICATIONS and prescribing meds is not in the nurses scope of practice. If the facility of the OP has a PharmD involved then that person should be the driving force behind such a policy. Nursing should of course have input in developing such a policy. I wouldn't be comfortable solely developing policy on something that involves giving MEDICATIONS. Yes I titrate them all the time but the sedation policy in my facility is driven by the Intensivist/PharmD/Critical Care Nurse Specialist according to the SCCM (Society of Critical Care Medicine) guidelines. In smaller facilities, such policies are usually driven by nurses but approved by the Medical Director of said ICU.

I NEVER said that nurses shouldn't write policies in general. I don't think that nurses should be the sole writer of policies involving medications.

ZASHAGALKA, RN · Dec 26, 2005

Candy,
Let me rephrase my original reply. I have no problem developing policies for generalized nursintg tasks. We do this all the time at my facility. Sedation protocols involve MEDICATIONS and prescribing meds is not in the nurses scope of practice. If the facility of the OP has a PharmD involved then that person should be the driving force behind such a policy. Nursing should of course have input in developing such a policy. I wouldn't be comfortable solely developing policy on something that involves giving MEDICATIONS. Yes I titrate them all the time but the sedation policy in my facility is driven by the Intensivist/PharmD/Critical Care Nurse Specialist according to the SCCM (Society of Critical Care Medicine) guidelines. In smaller facilities, such policies are usually driven by nurses but approved by the Medical Director of said ICU.
I NEVER said that nurses shouldn't write policies in general. I don't think that nurses should be the sole writer of policies involving medications.

Our Sedation Protocol, Insulin Protocol, and Electrolyte Replacement Protocol are all written and updated by a protocol committee composed of Nurses and Clinical Pharms. Once written, they are approved by the Medical Committee (The Docs) and Administrative Oversight.

Any Doctor can opt out of using the protocols, but unless specifically d/c'd as an order, they are standing orders, by order of the Medical Committee.

But I'll tell you one thing, If nurses aren't helping to write these protocols, they won't be very effective. You HAVE to involve the end user in the formation of a product if you want to see the product from the end user's point of view.

And I know that doesn't contradict what you said. I'm not challenging your point, but expounding on it.

~faith,

Timothy.

candyndel · Dec 29, 2005

Generalized nursing tasks...like bed baths? Why would one even need a policy for generalized nursing tasks? That's what our generic nursing programs were for!

If I am administering the MEDICATIONS then I am deciding (and I say that collectively) the best way to monitor their effectiveness. A medication policy such as this one doesnt bestow prescriptive privileges upon the staff nurse, but provides him/her with the tools needed to safely perform the high risk task once ordered.

It also protects the patient from inappropriate orders/useage and serious potential harm (examples: insulin, potassium, "old" propofol useage, nesiritide, ibutilide,etc etc etc ...I cant even get started on SGC's!).

Like I have already said, it is a nurse driven collaborative effort. And if you were my patient, you'd thank me for how much weight I place on patient advocacy in our myriad of nursing roles.

RNforLongTime · Dec 29, 2005

Generalized nursing tasks...like bed baths? Why would one even need a policy for generalized nursing tasks? That's what our generic nursing programs were for!

Actually, I think that it's a JCAHO rule that says something like if you perform it on a pt then there must be a written policy for it. I checked my facilities policy handbook and there are policies for bed baths AND bed making!

At YOUR facility Candy, the protocol may be nurse driven but at my facility which uses intensivists and Critical Care PharmD's, they drive the sedation protocol.

candyndel · Jan 20, 2006

WOW- That must be some book if you have a policy on every task a nurse does!

Here's the JCAHO reg on nursing policies...

Elements of Performance for NR.3.10

1. The nurse executive, registered nurses, and other designated nursing staff members write

nursing policies and procedures; nursing standards of patient care, treatment, and services;

standards of nursing practice; a nurse staffing plan(s)‡; and standards to measure,

assess, and improve patient outcomes.

2. The nurse executive is responsible for ensuring that nursing policies, procedures, and standards

describe and guide how the nursing staff provides the nursing care, treatment, and

services required by all patients and patient populations served by the hospital and as

defined in the hospital's plan(s) for providing nursing care, treatment, and services.

3. All nursing policies, procedures, and standards are defined, documented, and accessible

to the nursing staff in written or electronic format.

4. The nurse executive or a designee(s) exercises final authority over those associated with

providing nursing care, treatment, and services.