Emergency nurses' practices in assessing, monitoring and managing continuous intravenous sedation for critically ill adult patients

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Background: Between 2008 and 2012, the number of critically ill patients presenting to public Emergency Departments (EDs) in Australia increased by 34% (ATS 1 & 2, n=156,490); far higher than any other patient group. ED nurses are increasingly relied upon to assess and manage critically ill patients, some of whom require continuous intravenous sedation. While ‘balancing’ this sedation is a highly complex activity within a time-sensitive and highly pressured environment, there is little evidence within international literature relating to how ED nurses manage continuous intravenous sedation for the critically ill. Aims: The aim of this study was to explore emergency nurses’ practices in assessing, monitoring and managing continuous intravenous sedation for critically ill adult patients. Method: A two-phase sequential explanatory mixed methods study design incorporated a retrospective chart audit and semi-structured interviews. Ethical Approval: Ethical approval was obtained from university and health institutional ethics committees. Written informed consent was obtained from each participant prior to the commencement of data collection. All data were de-identified and anonymised. All data were stored in accordance with university and health institutional policies. Results: In Phase 1, the 12-month chart audit identified 55 patients received ongoing intravenous sedation within the ED. Median ED length of stay was 3.4 hours (range 0.8-11.3hrs), 59% were aged under 65 years and 68% male. Nursing documentation demonstrated that over 60% of patient assessments had respiratory rate, oxygen saturation, heart rate and blood pressure assessed hourly. Conversely, levels of consciousness, pain and end-tidal carbon dioxide were recorded in less than 10% of cases. Adverse events were documented in 21% of cases, with the majority drug administration related (16%). In Phase 2, 15 semi-structured interviews were conducted. Participants were predominantly female (n=12, 80%) and clinical nurse specialists (n=8, 53%) with at least 7 years (range 3-20 years) experience in the resuscitation area. The qualitative analysis yielded five themes: ‘becoming the resuscitation nurse’, how ED nurses transition into the resuscitation area; ‘the basics’, which outlined the knowledge, skills and expertise required as the resuscitation nurse; ‘becoming confident as the resuscitation nurse’, gaining confidence as the resuscitation nurse; ‘communicating about continuous sedation’ in the ED, how physicians and resuscitation nurses shared information about the use and titration of continuous intravenous sedation; ‘visual cues’, which outlined how nurses were prompted by the patient to alter sedation, and ‘the vanishing act’, the resuscitation nurse on their own. Conclusion: The study identified that the emergency nurse was responsible for the continuity of patient care, and optimisation of sedation and pain control for critically ill sedated patients. Emergency nursing practice often occurs in geographical isolation due to geographical layout of the resuscitation area and workload demands. While managing continuous intravenous sedation for critically ill patients in the ED was common, training, communication between medical staff and the resuscitation nurses about sedation was inadequate. Methods used to assess patients’ needs of sedation, including pain relief, were poor. There is a need to develop Australian guidelines to assist emergency nurses in assessing, monitoring and titrating sedation for the critically ill patient. By using guidelines, the safety and effectiveness of continuous intravenous sedation for the critically ill adult patient in ED is dependent on the skill, knowledge and decision-making abilities of the nurse if adverse events are to be minimised and safety and comfort enhanced.
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