Article Text
Abstract
Objectives Various strategies to promote light sedation are highly recommended in recent guidelines, as deep sedation is associated with suboptimum patient outcomes. Yet, the challenges met by clinicians in delivering high-quality analgosedation is rarely addressed. As part of the evaluation of a cluster-randomised quality improvement trial in eight Scottish intensive care units (ICUs), we aimed to understand the challenges to optimising sedation in the Scottish ICU settings prior to the trial. This article reports on the findings.
Design A qualitative exploratory design: We conducted focus groups (FG) with clinicians during the preintervention period.
Setting and participants: Eight Scottish ICUs. Nurses, physiotherapists and doctors working in each ICU volunteered to participate. FG were recorded and verbatim transcribed and inserted in NVivo V.10 for analysis. Qualitative thematic analysis was undertaken to develop emergent themes from the patterns identified in relation to sedation practice. Ethical approval was secured by Scotland A Research ethics committee.
Results Three themes emerged from the inductive analysis: (a) a recent shift in sedation practice, (b) uncertainty in decision-making and (c) system-level factors including the ICU environment, organisational factors and educational gaps. Clinicians were challenged daily to manage agitated or difficult-to-sedate patients in the era of a progressive mantra of ‘just sedate less’ imposed by the pain–agitation–delirium guidelines.
Conclusions The current implementation of guidelines does not support behaviour change strategies to allow a patient-focused approach to sedation management, which obstructs optimum sedation–analgesia management. Recognition of the various challenges when mandating less sedation needs to be considered and novel sedation–analgesia strategies should allow a system-level approach to improve sedation–analgesia quality.
DESIST registration number NCT01634451
- qualitative research
- quality In health care
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Footnotes
Contributors TSW was chief investigator, had the original idea for the study, secured funding, designed the project and contributed to study management and analysis. KK designed the qualitative process evaluation, and contributed to study management, data collection and analysis. JA contributed to study design and study analysis, was trial manager. JH contributed to study design, data collection and analysis. GH contributed to study analysis. All the authors reviewed and approved the final manuscript.
Funding The DESIST study was funded by a grant from the Chief Scientists Office, Scotland (Ref CZH/3/3), and by an unrestricted grant from GE Healthcare.
Competing interests GE Healthcare partly funded the DESIST study, as unrestricted support, but had no control over research design, data analysis or interpretation, manuscript writing or the decision to publish this study.
Ethics approval Ethical approval was secured by Scotland A Research ethics committee.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement No additional data are available.
Collaborators Anaesthetics, Critical Care and Pain Medicine (Prof T S Walsh MD, KK PhD, K Everingham PhD, E C Phillips MBChB), Edinburgh Clinical Trials Unit (JA BSc, J Stephen PhD), Centre for Population Health Sciences (R J Lee MSc, Prof C J Weir PhD), University of Edinburgh, Edinburgh, Scotland, UK; Edinburgh & Edinburgh Napier University, Scotland, UK (KK PhD, JH PhD); Edinburgh Health Services Research Unit, Edinburgh, Scotland, UK (JH, Prof C J Weir); GE Healthcare Finland Oy, Kuortaneenkatu 2, 00510 Helsinki, Finland (K Uutela PhD, P Peltola BN); Department of Anaesthetics, Ninewells Hospital, NHS Tayside, Scotland, UK (S Cole FFICM); Department of Anaesthetics, Glasgow University, Glasgow Royal Infirmary, Glasgow, Scotland, UK (T Quasim MD); Department of Anaesthetics, Monklands Hospital, NHS Lanarkshire, Scotland, UK (J Ruddy FFICM); Department of Anaesthetics, Victoria Hospital, Kirkcaldy, NHS Fife, Scotland, UK (M McDougall FRCA); Department of Anaesthetics, Victoria Infirmary, NHS GGC, Glasgow, Scotland, UK (A Davidson FFICM); Department of Anaesthetics, Dumfries and Galloway Royal Infirmary, NHS Dumfries and Galloway. Scotland, UK (J Rutherford PhD) and Department of Anaesthetics, Forth Valley Royal Hospital, NHS Forth Valley, Scotland, UK (J Richards FFICM). The DESIST investigators: ROYAL INFIRMARY EDINBURGH: Prof TSW, Dr Alasdair Hay (PI), Dr KK, Fiona Pollock, Louise Boardman, Corrienne McCulloch, Heidi Dawson, David Hope, Dr Kallirroi Kefala, Dr Michael Gillies, Louise Bell, Deborah Rodgers, Sue Wright, Dr Kirsty Everingham, Dr Emma Phillips. DUMFRIES AND GALLOWAY ROYAL INFIRMARY: Dr John Rutherford (PI), Dr Dewi Williams, Catherine Jardine. GLASGOW ROYAL INFIRMARY: Dr Tara Quasim (PI), Dr Alex Puxty, Steven Henderson, Naomi Hickey, Elizabeth Lennon, Jane Ireland, Natalie Dickinson, Marie Callaghan, Dominic Rimmer. VICTORIA INFIRMARY, GLASGOW: Dr Alan Davidson (PI), Katherine McGuigan, Anissa Benchiheub, Laura Rooney. FORTH VALLEY ROYAL HOSPITAL: Dr Jonathan Richards (PI), Janice Grant, Pamela Scott, Marianne Mallice. VICTORIA HOSPITAL, KIRKCALDY: Dr Marcia McDougall (PI), Claire McGinn, Sarah Gray, Keith Boath, Louise Doig, Lesley Berry, Edward Greenwood, Elish Daglish, Carolyne Bullions, Elaine Black, Donna Beattie, Elaine Paton, Alison Connelly, Nancy Hudson, Neville Tomkins, Julia Cook, Terry Hughes, Lynne Cairns, Jennifer Rowe, Ben Slater, Susan Russell, Bob Savage, Gavin Simpson, Ben Shippey. NINEWELLS HOSPITAL, DUNDEE: Dr Stephen Cole (PI), Louise Cabrelli, Jackie Duffy, Pauline Amory. MONKLANDS HOSPITAL: Dr James Ruddy (PI), Margaret Harkins, Elizabeth Reaney, Lyndsey Kearney, Angela Hamill, Isobel Paterson. EDINBURGH CLINICAL TRIALS UNIT: JA (Trial Manager), Ronald Harkess, Samantha Thomas. STATISTICAL TEAM: Dr Christopher Weir, Robert Lee, Jacqueline Stephens. GE HEALTHCARE: Petra Peltola, Kimmo Uutela, Lasse Kamppari, Mika Sarkela. LEARNPRO (Education Module): Christine Blaydon, Shaun McWhinnie. Edinburgh Health Services Research Unit: Dr Janet Hanley. Independent Data Monitoring Committee: Prof Danny McAuley (Chair); Prof John Norrie, Dr Stephen Wright.