NR 451 Week 6 Sedation Scoring Implementation Plan Example

Sedation Scoring Before Every Opioid Dose: An Implementation Plan for a Postoperative Surgical Unit

Student Name

College of Nursing, Chamberlain University

NR 451: RN Capstone Course

Instructor Name

Month Day, Year

Sedation Scoring Before Every Opioid Dose: An Implementation Plan for a Postoperative Surgical Unit

The Change Being Implemented

This plan puts into practice one change on a composite 32-bed postoperative surgical unit: before every dose of an opioid, and 30 minutes after every intravenous dose, the nurse scores the patient's sedation on the Pasero Opioid-Induced Sedation Scale and records it in the medication administration record, where the score becomes a required field. The scale runs from S, asleep and easy to arouse, through 1, awake and alert, and 2, slightly drowsy and easily aroused, to 3, frequently drowsy and drifting off during conversation, and 4, minimal or no response to verbal or physical stimulation (Pasero, 2009). A score of 3 means the dose is held, the patient is stimulated and monitored, and the prescriber is notified; a score of 4 triggers a rapid response call and naloxone per protocol.

The capstone's evidence review found that unintended advancing sedation reliably comes before opioid-induced respiratory depression and that sedation scoring detects it earlier than respiratory rate or oxygen saturation alone, especially in patients receiving supplemental oxygen (Jungquist et al., 2020). The unit currently records a pain score before opioid doses but no sedation score, and a review of the past year found two rapid response calls for oversedation in which the last documented assessment was a pain score of 7 given an hour earlier. The Joint Commission (2012) identified exactly this pattern, dosing to a pain number without assessing sedation, as a contributor to opioid-related adverse events in hospitals.

Stakeholders and What Each Is Needed For

Nurse manager: Approves the change, protects 30 minutes of each staff nurse's time for training, and signs the unit communication announcing the go-live date.

Clinical nurse educator: Builds and delivers the training, including case scenarios, and completes competency checks.

Nursing informatics specialist: Adds the scale as a required field in the medication administration record for every opioid, with a pop-up reminder at 30 minutes after intravenous doses; this build is the single step that cannot be done by the unit alone.

Surgical hospitalist and anesthesia pain service: Agree to the escalation pathway at scores of 3 and 4 and to receive calls when doses are held.

Pharmacy: Reviews the protocol for consistency with the existing naloxone standing order.

Charge nurses on both shifts: Serve as go-live resources and run the daily five-minute huddle check for the first four weeks.

Unit champions: Two staff nurses, one on each shift, who model scoring, answer questions and collect the weekly audit.

Timeline Anchored to Go-Live

Day minus 42: Capstone student presents the evidence and draft protocol at the unit practice council; nurse manager approval is requested.

Day minus 35: Informatics request submitted for the required field and 30-minute reminder; pharmacy and the anesthesia pain service review the protocol.

Day minus 28: Educator and champions complete training materials: a ten-minute video, four patient scenarios and a pocket card with the scale and actions.

Days minus 21 to minus 7: Training delivered at staff meetings and huddles on both shifts, with each nurse scoring three scenarios correctly to pass the competency; nurses who miss sessions complete the video and competency with a champion.

Day minus 3: Informatics field tested in the training environment by both champions.

Day 0 (go-live): Required field turned on; charge nurses carry the pocket card and review scores at the midday huddle.

Days 1 to 28: Daily huddle check of one opioid administration per nurse; champions audit ten doses per week and give same-day feedback.

Day 30: First audit report to the practice council; protocol revisions if needed.

Day 90: Transition of the audit to the unit's routine quality dashboard.

Resources

The change needs little money but real time. Training costs about 30 minutes of paid time for each of 58 nurses on the unit, roughly 29 hours in total, which the nurse manager has agreed to cover from the education budget. Champion time adds about two hours per week for each champion during the first month. The informatics build is estimated by the informatics team at six hours. Printing the pocket cards costs under 50 dollars. No new equipment is needed. The main resource at risk is the informatics queue; if the build is delayed, the plan will launch with a paper sedation flowsheet at the bedside for two weeks, which is less reliable but keeps the training from going stale.

Barriers and Responses

The group most likely to resist is experienced night nurses, for two reasons they have already voiced at huddles: waking a sleeping patient to score sedation before a dose feels unkind, and one more required field adds time at 0200 when a nurse has six patients. The plan answers both. The scale itself includes S for a patient who is asleep and easy to arouse, and the training teaches that confirming arousability is the point of the score, so the nurse wakes the patient only enough to confirm the level, which is also what would be needed to give an oral dose safely anyway. On time, the educator timed the scoring in the scenarios at under 30 seconds, and the required field replaces the free-text note some nurses already write about drowsiness, so the net documentation time should be close to zero.

A second barrier is that prescribers may resist being called when doses are held. The anesthesia pain service's agreement to the escalation pathway before go-live is the response, and calls for a score of 3 will be made through the existing secure messaging system rather than by page. A third barrier is alert fatigue if the 30-minute reminder fires for oral doses; the informatics build limits it to intravenous doses.

Sustaining the Change After the Project

The capstone student will not be on the unit after the term, so ownership is assigned before go-live. The clinical nurse educator owns the protocol and its annual review. The champions continue the weekly audit for 90 days, after which the percentage of opioid doses with a documented sedation score becomes a line on the unit quality dashboard reviewed monthly by the nurse manager. New nurses complete the scenarios as part of unit orientation. Every rapid response call for oversedation will be reviewed at the practice council with the sedation scores preceding it, which ties the change to the harm it is meant to prevent. Jungquist et al. (2020) recommend that sedation monitoring become part of institutional policy rather than a unit habit, and the practice council will forward the protocol to the hospital's pain committee at the 90-day mark as a candidate for other surgical units.

References

Jungquist, C. R., Quinlan-Colwell, A., Vallerand, A., Carlisle, H. L., Cooney, M., Dempsey, S. J., Dunwoody, D., Maly, A., Meloche, K., Meyers, A., Sawyer, J., Singh, N., Sullivan, D., Watson, C., & Polomano, R. C. (2020). American Society for Pain Management Nursing guidelines on monitoring for opioid-induced advancing sedation and respiratory depression: Revisions. Pain Management Nursing, 21(1), 7-25. https://doi.org/10.1016/j.pmn.2019.06.007

Pasero, C. (2009). Assessment of sedation during opioid administration for pain management. Journal of PeriAnesthesia Nursing, 24(3), 186-190. https://doi.org/10.1016/j.jopan.2009.03.005

The Joint Commission. (2012). Safe use of opioids in hospitals (Sentinel Event Alert No. 49). https://www.jointcommission.org/resources/sentinel-event/sentinel-event-alert-newsletters/