ICU Sedation Management Checklist

High Risk—High Alert Medications
 Is the patient's RASS goal appropriate for his/her current condition?
Name two High Alert Medications on your Unit?
 Are the RASS goals updated on EACH medication?
Examples: Insulin, Heparin (make sure they apply to your unit)
 If the RASS assessment doesn't match the current RASS goal, are you Why are they High Alert Medications on your Unit?
intervening? Example: Insulin
 Is the patient appropriate for a Daily Sedation Interruption (DSI)/  Narrow Therapeutic Range– small changes in dose may lead to side effects.
Sedation Awakening Trial (SAT)?  Multiple kinds of insulin– look alike, sound alike.
 Have you performed and documented the DSI/SAT? Example: Heparin
 Pass or fail?  Narrow Therapeutic Range
 If the patient passed the DSI/SAT, did you restart the continuous se-  Complex dosing that may lead to adverse effects.
dation at 50% of the rate? What are some safe guards in place with these High Alert Medications?
 Does your documentation reflect sedation rate titration? Examples:
 Have you completed and documented the CAM-ICU appropriately?  Insulin & Heparin: independently checked by two licensed caregivers prior to ad-
Timeline of improvements: ministration.

 Sedation Bundle Implementation started several years ago  Tall Man Letters (Pyxis, PowerChart, Medication Labels): HumuLIN HumaLOG
 Nursing and Pharmacist re– education 2015-2016  Insulin 500units/mL and long acting insulin (Insulin Glargine) are stocked in pharmacy
and dispensed unit dose per patient.
 PowerPlan updates 2015-2016 (analagosedation approach to orders)
 Heparin cannot be overridden in Pyxis for removal; Heparin solutions are stored sepa-
 Daily MDR sedation data collection started in Fall 2016
rately from other IV solution. Heparin vials of different strengths are stored separately
 Great Progress so far! Improved compliance with DSI/SAT; Improved compliance in Pyxis.
with policy regarding restart of sedation med at ½ rate; Decrease in overall sedative Reference: Administrative Policy- High Risk High Alert Medications
use – therefore decrease in side effects, delirium, etc. **Posters have been hung by all Pyxis machines**
**Pharmacists should be able to speak to MDR data collection happening
daily**
Medication Orders—PRN medications
Reference: PCS Intensive Care Units Policy—Daily Sedation Interruption (DSI) or Multiple Routes of Administration: Which medication to select?
Spontaneous Awakening Trial (SAT) Example: Hydromorphone 0.5 mg IV push Q3h, prn, pain – moderate
Hydrocodone/Acetaminophen 5 mg/325 mg 1 tab PO Q4h prn, pain – moderate
Key Decision Criteria:
1. Ascertain that all options are viable for the patient (i.e. Ability to swallow, level of conscious-
OR and Procedural Areas: ness, presence of IV access, presence of nausea and vomiting).
2. The IM route is the least preferable for most medications due to patient discomfort and
 Confirm Warmer Temperature documentation (see warmer policy)
fluctuations in absorption.
 Confirm syringes and multi-dose vials are properly labeled 3. If rapid response is needed (i.e. severe pain level, new post-operative patient) consider
 Syringes: labeled with med name, strength, amount of medication or absorption time of IV versus oral administration.
4. Consider patient preference and effectiveness of previously administered doses.
amount of solution containing medication, beyond use date and time
Make sure to clarify any therapeutic duplications
 Multi-dose vials: labeled with beyond use date of 28 days (types of PRN orders: pain, antiemetic, constipation, etc)
Reference: Example:
Administrative Policy—Fluid Warmers—Medication Expiration Acetaminophen 650 mg/ 2 Tab PO Q4h PRN Pain-Mild/Fever greater than 100.4
Ibuprofen 600 mg/ 1 Tab PO Q6h PRN Pain - Mild
Administrative Policy– Medication Labeling in Perioperative and Other
HYDROcodone/Acetaminophen 5 mg/325 mg 1 Tab PO Q4h PRN Pain - Moderate
Procedural Settings HYDROmorphone 1 mg/ 1 mL IV Push Q4h PRN Pain - Severe

January 2019 
 
   

Medication Overrides in Pyxis: Pain Management Standards

New Joint Commission Standard in 2018
Joint Commission Standard requires pharmacist review of all medica-
Pain Management policy—found in Administrative Policies & Procedures
tion orders. Two exceptions are allowed:
 Pain management includes pharmacological and non-pharmacological interven-
(1) When a Licensed Independent Practitioner (LIP) controls the ordering, prepa-
tions, which is individualized based on the patient’s condition and goals for care
ration, and administration of the medication
as well as his/her cultural, personal, and spiritual beliefs.
(2) When a delay would harm the patient in an urgent/emergency situation in-
 Pain is assessed using one of the 5 following scales: (1) NIPS – Full term and
cluding sudden changes in a patient’s clinical status
preterm infants to 1 year (2) Numeric Rating Scale (Adult) - Rated using a 0-10
Reference: Pharmacy Policy: Automated Dispensing System- Medica- numeric scale where “0” is no pain and “10” is the worst possible pain.
tion Overrides (3) FACES – Intended for children 4 – 16 years of age, older adults and those
Verbal or Telephone Orders: who are mildly to moderately cognitively impaired (4) Pain Assessment in Ad-
vanced Dementia (PAINAD) – Intended for adults with moderate to advanced
Verbal or telephone orders are to be limited and restricted to:
dementia. (5) The Critical Care Pain Observation Tool (CPOT) – For verbal and
 Emergent situations
nonverbal adult intensive care unit patients. The four categories (facial expres-
 When clinical situations make it impractical for orders to be entered into the sion, body movements, muscle tension, compliance with the ventilator) are
EHR or written on the appropriate form for the non-EHR sites. scored 0-2, which results in total score of 0-8.
 Situations when Practitioners do not have access to remote computer devices  Patient education is provided at discharge for patients discharged with pain
or the patient’s chart. medications.
Reference: Administrative Policy: Physician Orders
 Annual pain management education for all colleagues through HealthStream
Palliative Ventilator Withdrawal (PVW) Policy education modules - for 2019 Smart Rx education has been assigned to Phar-
1. PVW Power Plan must be utilized macy, Nursing, and Physicians.
2. Practitioner must electronically enter their own PVW Power Plan orders Medication Storage and Security
3. No verbal orders for PVW Power Plan
 All medications must be secured AT ALL TIMES
4. Medication dosing outside of Power Plan, or medications not included on
 Patient med bins/raspberry bins should be closed and locked, no medications in
Power Plan, Practitioner must obtain approval per policy
your pocket, no medications on the counter or in the nursing station, no medica-
5. Practitioner or RN cannot administer PVW medications until verified by phar-
tions sitting in the tube station, etc.
macy
Reference: Patient Care Services Policy: Palliative Ventilator Withdrawal What is the appropriate amount of time to waste a controlled substance?
Immediately or within 1 hr, document waste in Pyxis.
Antimicrobial Stewardship Program Where do you waste controlled substances?
Goal: Decrease unnecessary and inappropriate use of antibiotics and Squirt or Flush to ensure irretrievability
associated side effects of overuse, including antibiotic resistance
Patient Education:  Fentanyl patches must be folded and flushed
Patient education regarding antibiotics is automatically included in discharge edu-  Injectable solutions squirt out into the sink or toilet (Examples: IVs,
cation materials. PCAs, Hydromorphone)
Regional Committee: Meets every other month and reports to P&T committee  Oral and suppository drug content to be flushed—not crushed
annually
What do you do if a patient brings in their own medications?
Performance Improvement (PI) Focus for 2018-2019:
Should be sent home with family or given to safety and security for safe keeping. If
(1) Fluroquinolone Days of Therapy, (2) Ertapenem Restriction Adherence
a patient requires use of home medication for their care it should be sent to the main
(3) Ceftaroline, Daptomycin Restriction
**AMS Pharmacists and ID Physicians should be able to speak to data in PI pharmacy for identification and to check integrity prior to administration.
Plan** Reference:
Reference: Administrative Policy—Antimicrobial Stewardship Policy Pharmacy Policy—Controlled Substances-Schedule II – V; Pharmacy Policy—
Pharmaceutical Waste Disposal; PCS Policy –Medication Brought from Home

January 2019