Sedation Vacation

Jennifer Aguirre, Ray Alvarado, Brita Furr, Emilee Hawk, Leann Huso,
Diana Hess, Crystal Maciel, Hannah Ridinger, Janelle Westbrook,

What is sedation vacation?

Hold the sedation and opioid infusion each day until the patient
wakes up and can follow simple commands

Restarted at predetermined dose according to protocol if necessary

for maintenance of patient comfort, and then titrated accordingly

Goals of sedation vacation

Optimize sedation and analgesic therapy

Guide titration of therapy to maintain a pain-free and arousable state

Avoid oversedation of patients

(Kher et al., 2012; Mehta S., 2012)

Ultimate Goal

The ultimate goal of sedation vacation is to

reduce length of stay, decrease incidence of

ventilated associated pneumonia, and shorten
mechanical ventilation duration.

Sedation Vacation

The goal of sedation vacation is to

optimize sedation and analgesic
therapy, and to guide titration of
therapy to maintain a pain-free and
arousable state, in order to avoid oversedation of patients.
(Kher et al., 2012)

PICOT Question

(P) In adult ICU patients (T) that are mechanically

ventilated for more than 24 hours, (I) does daily

awakening (O) result in better outcomes, including
shorter mechanical ventilation duration and
reduced length of intensive care unit (ICU) stay,
(C) compared to continuous sedation?

Summary of Current
Practice
Criteria for patient eligibility for sedation vacation

Spontaneous Awakening Trials Safety Screen

No active seizures

No alcohol withdrawal

No agitation

No paralytics

No myocardial ischemia

Normal intracranial pressure

At St. Josephs, this is not currently implemented on a consistent basis.

(American Association of Critical Care Nurses, 2011)

Does sedation vacation

help?
It reduces the number of days of mechanical ventilation and

does not adversely affect patient comfort, safety, or postICU psychological health
Does not increase rates of reintubation
It reduces the likelihood of ventilator associated events per

mechanical ventilator episode (pneumonia, ARDS,

thromboembolisms, pulmonary edema, atelectasis and
delirium)
VAEs increase patient length of stay and patient mortality

(Kher et al., 2012; Klompas et al., 2015).

Does sedation vacation

help?

Reducing sedation levels during daytime results in

increased levels of REM and slow wave sleep, and use
of less medication for pain and anesthesia

REM and slow wave sleep are associated with improved

rates of healing

Less use of pain and sedation medication results in lower

costs to the patient and hospital

Sedative exposure may be one factor that leads to the

adverse cognitive outcomes now recognized to occur
in a significant portion of ICU survivors
(Jackson et al., 2010; Oto et al., 2011 )

Is it being implemented?

Compliance rate of 54-72%,

One study used self-reporting
Compliance rate was 80%,

suggesting that nurses overestimate

their actual compliance rate
(Mendez et al., 2013; Mehta et. al,2012; Ackrivo et al, 2015; Miller et al., 2012)

Why is there
incompliance?
Institutional and unit culture
Staff receptivity to change
Patient discomfort, patient safety, additional

workload for nurses, and possibility of patient

experiencing respiratory distress
Possibility of patient-initiated device removal
(Hogue & Mamula, 2013; Kher et al., 2012; Mehta et. al,2012; Miller et al., 2012)

Why is there
incompliance?

The level of skill may be different between nurses

Assessments and performances of sedation vacation may be

inaccurate

Maximal ventilator or hemodynamic support, Riker Sedation

Agitation Score 6 or heightened sedative requirement, and
active alcohol withdrawal can make patients ineligible for
sedation vacation

(Ackrivo et al, 2015)

How to change nurses

perceptions?

Clarify to staff that common perceptions about

sedation vacation are not evidence based

Staff should be encouraged to use other means of

calming patients without giving additional sedatives

Educate ICU team about national sedation guidelines

and the importance of adhering to them

Provide protocols for the staff and educate the nurses

on how to implement sedation vacation
(Ackrivo et al, 2015; Khan et al., 2014; Kher et al., 2012; Klompas et al.,2015)

How to change nurses

perceptions?
Educate staff about the benefits of targeted light

sedation

Sedative medications may contribute to adverse

psychological outcomes

Some patients who experience sedative-induced

delusions while in the ICU, are more likely to develop
PTSD than patients who have factual memories of
their ICU stay

(Jackson et al., 2010; Mehta, 2012)

How to Increase
Compliance Rates
A dedicated ventilator rounding team:

attending physician, nursing unit leader, respiratory

therapist, and a pharmacist

Round the unit every weekday morning at 0800

Was it performed?
Provide immediate feedback to the nurse if
incompliant

(Kher et al., 2012)

How to Increase
Compliance Rates
Use of triggers to prompt nurses to complete

sedation vacation
Integration of a structured protocol to enhance

implementation

coordinates spontaneous breathing trials, delirium

management, and early mobilization

(Kher et al., 2012; Miller et al., 2012)

Strengths of Current
Research

Most of the studies had large sample sizes and were

conducted over several months.

Diverse healthcare settings

They took ethnicity, sex, and age into consideration.

The findings and results from the articles were congruent.

(Khan et al., 2014; Klompas et al., 2015; Mehta S., 2012; Mendez et al., 2013; Ackrivo et al., 2015; Oto et al.,
2011)

Weaknesses of Current
Research

Majority of studies were not randomized controlled studies.

No standardized measurement of compliance.

One study:

Used a survey, rather than a bedside audit of compliance

Had the lead infection control specialist of the organization be the

reporter

Hawthorne Effect

Not randomized or blinded because of nature of intervention.

Research studies depended on self reporting ~ documentation.

(Ackrivo et al, 2015; Khan et al., 2014; Mendez et al.; Miller et al., 2012; Oto et al., 2011)

EBP Recommendation #1

Providing automatically generated reminders to

nurses for daily sedation vacation.

Implementation: Generate an order/task to be

included for all continuously-sedated patients to
complete sedation vacation at a scheduled time each
day, unless the patient meets the pre-determined
exclusion criteria. Research shows that triggers to
remind the nurse of sedation vacation increases
compliance rates.

(Kher et al., 2013; Klompas et al., 2015)

EBP Recommendation #2

Encouraging increased accountability for adherence to daily

sedation vacation protocol.

Implementation: Include a section within Cerner that

requires completion of documentation of sedation vacation,
and requiring nurses to provide a reason for not completing
the sedation vacation, if applicable. Research shows that
requiring measurement and reporting of actual performance
of sedation vacation increased rates of adherence to daily
sedation vacation.

(Kher et al., 2013; Klompas et al., 2015)

EBP Recommendation #3

Encouraging compliance by utilizing an interdisciplinary team to

evaluate nurse adherence to completion of daily sedation vacation.

Implementation: During interdisciplinary rounding, the nurse will

inform the members of the rounding team whether or not each
eligible mechanically ventilated patient is receiving the required
sedation vacation. If the nurse is not complying with the hospital
policy, the charge nurse is responsible for addressing the nurses
noncompliance with sedation vacation. Research shows that a
multi-disciplinary team approach increased compliance rates of
daily sedation vacation and provided immediate feedback to the
nurses.

(Kher et al., 2013; Mendez et al., 2013; Miller et al., 2012)

EBP Recommendation #4

Educating nurses about the evidence-based research

regarding sedation vacation, including evaluation of the
patients eligibility for sedation vacation.

Implementation: Institution of a mandatory online workshop

module that educates nurses about the benefits of daily
sedation vacations and addresses the misperceptions and
concerns of the nurses regarding sedation vacation. Research
shows that by increasing the knowledge of how and when to
implement sedation vacation, nurse compliance rates
increase.

(Ackrivo et al., 2015; Kher et al., 2013; Klompas et al., 2015; Miller et al.,
2012)

Cost of Implementation

Online Education Workshop Module ~ 1 Hour Module

Average wage of a RN is $31.48 per hour, but ICU nurses have higher wages

paid for time in the workshop in addition to regular wage during shift

Cost of creating a module

The average rate is $116 per hour X 383 hours of development for a 1 hour
module

Total Cost: $44,428

Updating Cerner

New task

document section in nursing flowsheet

(Bureau of Labor Statistics, 2014; Karrer, 2009)

Cost-Saving Effects of
Implementation
Decreases patient length of stay in the ICU by three days
One day in ICU costs $4,004
An incidence of VAP can increase hospital costs by $40,000 per stay,

per patient
DSI can lead to decreased use of pain and sedative medications
Costs are higher in patients who experience delirium than in those

patients who do not

ICU costs $22,346 versus $13,332; total hospitalization costs $41,836
versus $27,106)
(Critical Care Societies Collaborative, n.d.; Dotson, 2010; Huynh et al., 2013; Klompas et al., 2015; Oto et al.,
2011)

SMART Outcomes

Monthly chart audits performed on the last day of

each month will show an increase in compliance rates
from the previous months compliance rate by 10%.

Every morning, the multidisciplinary team involved

with ensuring the patient is receiving the required
sedation vacation will round and document the
occurrence as a progress note after encounter.

Every year, a mandatory workshop on sedation

vacation will take place to educate and update nurses
on the latest evidence procedures.

Evaluations of Outcomes

Not Implemented It is likely that implementation of daily

reminders would result in increased rates of compliance.

Not Implemented It is likely that implementation of a

rounding team would result in more accountability for
adherence to enforce daily sedation vacation.

Not Implemented It is likely that scheduling mandatory

workshops that provide nurses with knowledge concerning
benefits and the proper implementation of sedation
vacation will increase rates of compliance.

Patients Risk vs. Benefit

Benefits:

Lowers risk of VAP (Ventilator Associated Pneumonia)

Lowers risk of delirium

Decreases length of hospital stay

Increases level of REM and slow-wave sleep, which are associated with
improved rates of healing.

Reduces pain medication

Lowers incidence of PTSD

Decreases exposure to sedatives and their side effects

Risks:

Feelings of discomfort, pain, agitation

(Klompas et al., 2015; Mendez et al., 2013; Jackson et al., 2010; Mehta et al., 2012; Kher et al., 2012; Oto
et al., 2011; Dotson, 2010)

Nurses Risk vs. Benefit

Benefit:

Ability to titrate sedation accurately.

Multidisciplinary resources and support increases

compliance.

Risk:

Increases nurse workload.

(Kher et al., 2012; Varshney, 2013; Dotson, 2010; Mehta et. al,2012)

Hospitals Risk vs. Benefit

Benefit:

VAP incidence is decreased. VAPs are a never event.

Incidence of tracheostomies was reduced.

Low rate of re-intubations.

Risk:

There is no guarantee that the money spent on recommended guidelines will

increase nurse compliance.

Patients may extubate themselves once on light sedation

Increased costs of sedation because larger doses may be needed to re-sedate

patients.

Is there more money spent on recommendations than saved from recommendations?

(PulmCCM, 2014; Klompas et al., 2015; Mendez et al., 2013)

References

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(2015). Successful implementation of an automated sedation vacation process in intensive
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Critical Care Societies Collaborative. (n.d.). VAE. In Critical Care Societies Collaborative.
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Hogue, M. D., & Mamula, S. (2013). Sedation vacation: Worth the trip. Nursing2015 Critical
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References Continued

Jackson, J. C., Girard, T. D., Gordon, S. M., Thompson, J. L., Shintani, A. K., Thomason, J. W., . .
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A. (2014). Effectiveness of implementing a wake up and breathe program on sedation and
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Kher, S., Roberts, R. J., Garpestad, E., Kunkel, C., Howard, W., Didominico, D., . . . Devlin, J. W.
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Klompas, M., Anderson, D., Trick, W., Babcock, H., Kerlin, M. P., Li, L., . . . CDC Prevention
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Mehta, S., Burry, L. F., Cook, D. F., Fergusson, D. F., Steinberg, M. F., Granton, J. F., . . . Meade,
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References Continued

Mendez, M. P., Lazar, M. H., Digiovine, B., Schuldt, S., Behrendt, R., Peters, M., & Jennings, J.
H. (2013). Dedicated multidisciplinary ventilator bundle team and compliance with sedation
vacation. American Journal of Critical Care : An Official Publication, American Association of
Critical-Care Nurses, 22(1), 54-60. doi:10.4037/ajcc2013873 [doi]

Miller, M. A., Krein, S. L., Saint, S., Kahn, J. M., & Iwashyna, T. J. (2012). Organizational
characteristics associated with the use of daily interruption of sedation in US hospitals: A
national study. BMJ Quality and Safety, 21(2), 145-151. doi:10.1136/bmjqs-2011-000233

Oto, J., Yamamoto, K., Koike, S., Imanaka, H., & Nishimura, M. (2011). Effect of daily sedative
interruption on sleep stages of mechanically ventilated patients receiving midazolam by
infusion. Anaesthesia and Intensive Care, 39(3), 392-400.

PulmCCM. (2014). Do "Sedation Vacations" Really Speed Weaning From Mechanical

Ventilation?. Retrieved from http://pulmccm.org/main/2013/randomized-controlledtrials/sedation-vacations-dont-reduce-ventilator-or-icu-days-in-large-trial-rct-jama/

Varshney, U. (2013). Smart medication management system and multiple interventions for
medication adherence. Retrieved from
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