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To identify the extent of compliance with the

use of RASS tool in ITU patients with an aim to


make improvements
- Satya Pal Singh
ST2
BACKGROUND
Many sedation scores available
Due to concerns regarding over
and under sedation in ICU
To titrate sedation to optimum
level for the patient
Objective means of assessment
UHNM uses RASS Score
METHODOLOGY
Retrospective study to look into
target RASS prescription
RASS assessment
whether the change in RASS was actioned by a change in sedative infusion
rates
Randomly assessed 30 ITU patients charts at different times
Also looked into the awareness about RASS score among the nursing
staff
RESULTS
Audit of 30 ITU charts
RASS score target prescribed : 8/30
RASS scoring done daytime 2 hrly : 10/30
RASS scoring done night 4 hrly : 13/30
Change in RASS actioned : 3/5
Could tell how RASS is calculated : 18/30
DISCUSSION
RASS target prescribed : 27%
RASS scoring done daytime: 33%
RASS scoring done nighttime: 43%
Change in RASS actioned: 60%
Awareness about RASS: 60%
INDICATIONS FOR SEDATION & ANALGESIA
tolerance of endotracheal tube and IPPV
tolerance of invasive monitoring (insertion)
tolerance of interventions e.g. suctioning, prone positioning
relief of psychological distress
analgesia post-operatively or post-trauma
relief of agitation
reduction in raised intracranial pressure/ prevention of surges in ICP
reduction in oxygen demand and oxygen consumption
simulation of sleep wake cycles
EFFECTS OF INADEQUATE SEDATION/
ANALGESIA
agitation and confusion
inadvertent removal of invasive monitoring
inadvertent removal of endotracheal tube
ventilator dysynchrony
rises in ICP
CVS instability
Increased O2 demand
Post traumatic stress disorder
Sympathetic activation (tachycardias, hypertension, tachypnoea)
Poor pain control
Adverse physiological responses (hypercoagulability, immunosupression)
EFFECTS OF EXCESSIVE SEDATION/ ANALGESIA
Prolonged weaning from ventilator and increased LOS on ICU
Inadequate cough / clearance of secretions
Increased exposure to side effects (e.g. hypotension, bradycardia,
increased lipid loads)
Difficulty assessing neurological function or changes in status
Risk factor for ventilator associated pneumonia
Post ICU psychological stress (related to prolonged amnesia)
RESULTS
Audit of 30 ITU charts
RASS score target prescribed : 8/30 (27%)
RASS scoring done daytime 2 hrly : 10/30 (33%)
RASS scoring done night 4 hrly : 13/30 (43%)
Change in RASS actioned : 3/5 (60%)
Could tell how RASS is calculated : 18/30 (60%)
CAUSE/DEFICIENCIES
Doctors
Target RASS prescription
What target to prescribe?- no specific guideline
Nurses
Awareness- Being addressed by Rehab Team
Commitment- addressed after introduction of Centricity On-line
RECOMMENDATIONS
RASS Calculation in all ITU patients
Daytime 2 hrly, night 4 hrly, and PRN
Prescribe Target RASS in all ITU patients
ACTION PLAN
Recommending changes as to how frequently the RASS scoring
should be done (the Trust ICM guidelines are lacking in this aspect)
Teaching sessions for the Doctors
Information to new doctors on Induction
FOLLOW-UP
Re-audit in 2 months after implementation of action plan