NR 449 Week 4 Sedation Trial Stakeholder Analysis Example

Pairing Daily Sedation Interruption With Breathing Trials: A Stakeholder Analysis for a Medical Intensive Care Unit

Student Name

College of Nursing, Chamberlain University

NR 449: Evidence Based Practice

Instructor Name

Month Day, Year

Pairing Daily Sedation Interruption With Breathing Trials: A Stakeholder Analysis for a Medical Intensive Care Unit

The Change Being Analyzed

The change is to pair two routines that already exist separately on a composite 20-bed medical intensive care unit. Each morning, nurses would stop continuous sedative infusions for eligible ventilated patients, a spontaneous awakening trial, and respiratory therapists would then perform a spontaneous breathing trial on patients who pass the awakening screen. At present, the unit performs breathing trials most mornings but interrupts sedation only when a physician orders it, so many breathing trials are performed on patients still receiving sedatives. The evidence for pairing is strong: in the Awakening and Breathing Controlled trial, patients managed with paired awakening and breathing trials had more ventilator-free days and lower mortality at one year than patients receiving breathing trials with usual sedation (Girard et al., 2008). The evidence is not in question here. What is in question is who has to agree and who has to change what they do.

National guidance points the same way. The 2018 intensive care guidelines on pain, sedation, delirium, mobility and sleep, often called the PADIS guidelines, suggest using either daily sedative interruption or nurse-protocolized light sedation for mechanically ventilated adults, rather than deep sedation by default (Devlin et al., 2018). The unit's current practice, interrupting sedation only when a physician remembers to order it, falls short of both options.

The analysis uses two lists. The permission list holds the parties without whose sign-off the change cannot proceed. The example list holds the people whose practice the unit actually copies. The two lists overlap only partly, and the difference between them is the argument of this paper.

The Permission List

Medical director of the intensive care unit: Owns the decision to make paired trials the unit's default, replacing the current requirement for a physician order to interrupt sedation. Cost: some loss of individual physician discretion, since the protocol would let nurses stop sedation without calling first. What would have to be true: a clear list of exclusions and a way for a physician to opt a patient out.

Pharmacy and therapeutics committee: Owns the sedation protocol document and any change to the rules for restarting infusions. Cost: a meeting cycle, typically six to eight weeks. What would have to be true: the protocol must specify how sedation is restarted, at what dose, after a failed awakening trial.

Respiratory therapy manager: Owns the respiratory therapists' morning schedule. Cost: breathing trials would need to wait until the awakening trial is complete, which may push some trials later in the morning and compress the therapists' rounds. What would have to be true: a predictable time window for awakening trials to finish.

Intensive care nurse manager: Owns the nurses' morning workflow and education time. Cost: about two hours of education per nurse and the need to staff for the first weeks when awakening trials take more attention. What would have to be true: a reason to believe the change will not increase self-extubations.

Clinical informatics: Owns the order set and the flowsheet. Cost: build time for a nursing screen that records awakening trial eligibility and outcome. What would have to be true: approval from the committees above.

The Example List

The senior night nurse on the unit's longest-running rotation: Twenty years in the unit, no title, and the person newer nurses watch when a patient becomes agitated. If she stops sedation at 0600 and manages the patient calmly, others will follow; if she leaves infusions running because she does not trust the protocol, many will do the same. Cost: the awakening trial falls near the end of her shift, when she is handing off. What would have to be true: permission to perform awakening trials at the start of the day shift instead, which means the day nurses must own them.

The respiratory therapist who leads morning rounds: Other therapists follow the sequence he sets. Cost: waiting for nurses before starting trials. What would have to be true: a reliable signal from the nurse that the awakening trial has passed or failed.

The day charge nurse on weekdays: Sets the tone for the morning huddle. Cost: another item on the huddle list. What would have to be true: a single question she can ask at huddle, such as which ventilated patients passed their awakening trial.

Objections Sorted by Kind

Objections raised in informal conversations fall into two kinds, and they need different answers. Clinical objections include the fear that stopping sedation will cause self-extubation, dangerous agitation or post-traumatic stress, and the concern that some patients, such as those with elevated intracranial pressure or on neuromuscular blockers, should never have sedation stopped. These deserve evidence and exclusion criteria. In the trial, self-extubation was more common in the intervention group, but reintubation rates after self-extubation were similar, and the trial specified safety screens and exclusions (Girard et al., 2008). A protocol that copies those screens answers the clinical objection directly.

Cost objections are about time and sequence: nurses worry that awakening trials add work in the busiest hour of the morning, and therapists worry that waiting for nurses will delay their rounds. These are not answered by evidence but by design, specifically by setting a time window that suits both groups. Treating a cost objection as resistance to evidence misses the point, and treating a clinical objection as a scheduling problem is unsafe.

A third kind of objection is really a question about accountability. Several nurses asked who would be blamed if a patient self-extubated during an awakening trial started under a protocol rather than an order. That question belongs to the medical director and the nurse manager, and the protocol should answer it in writing: a nurse who follows the protocol's screen and monitoring steps is acting within an approved standard, and events will be reviewed as system events rather than individual errors. Until that sentence exists, the most careful nurses are the ones most likely to hold back.

Where the Two Lists Diverge

The permission list could approve this change in two months and the unit could still not adopt it. The medical director, the committee and the managers control documents and schedules; the senior night nurse, the lead therapist and the day charge nurse control what actually happens at 0700. The most important decision in this analysis follows from that gap: awakening trials should be scheduled for the start of the day shift, so that the nurses whose practice spreads fastest own them from the beginning, rather than at the end of the night shift, where the most trusted nurse is least able to do them. Balas and colleagues' work on the wider sedation and delirium bundle points to the same conclusion, that bundles succeed when coordination between nursing and respiratory therapy is built into the routine rather than assumed (Balas et al., 2014).

References

Balas, M. C., Vasilevskis, E. E., Olsen, K. M., Schmid, K. K., Shostrom, V., Cohen, M. Z., Peitz, G., Gannon, D. E., Sisson, J., Sullivan, J., Stothert, J. C., Lazure, J., Nuss, S. L., Jawa, R. S., Freihaut, F., Ely, E. W., & Burke, W. J. (2014). Effectiveness and safety of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle. Critical Care Medicine, 42(5), 1024-1036. https://doi.org/10.1097/CCM.0000000000000129

Devlin, J. W., Skrobik, Y., Gélinas, C., Needham, D. M., Slooter, A. J. C., Pandharipande, P. P., Watson, P. L., Weinhouse, G. L., Nunnally, M. E., Rochwerg, B., Balas, M. C., van den Boogaard, M., Bosma, K. J., Brummel, N. E., Chanques, G., Denehy, L., Drouot, X., Fraser, G. L., Harris, J. E., . . . Alhazzani, W. (2018). Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Critical Care Medicine, 46(9), e825-e873. https://doi.org/10.1097/CCM.0000000000003299

Girard, T. D., Kress, J. P., Fuchs, B. D., Thomason, J. W. W., Schweickert, W. D., Pun, B. T., Taichman, D. B., Dunn, J. G., Pohlman, A. S., Kinniry, P. A., Jackson, J. C., Canonico, A. E., Light, R. W., Shintani, A. K., Thompson, J. L., Gordon, S. M., Hall, J. B., Dittus, R. S., Bernard, G. R., & Ely, E. W. (2008). Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): A randomised controlled trial. The Lancet, 371(9607), 126-134. https://doi.org/10.1016/S0140-6736(08)60105-1