Background
The modern healthcare sector faces multiple challenges, and some of these obstacles are related to the increased variety of problems patients might experience in intensive care units (ICUs). The increasing level of demands pertinent to vulnerable patients means that healthcare workers have to select new methods of care delivery and innovative approaches that would help patients attain positive outcomes and reduce complications. This project will discuss the optimal approaches of using bispectral index (BIS) monitors to prevent inadequate sedation for ICU patients.
The problems associated with the sedation of patients in ICU are widely discussed by scientists. Since the ICU accommodates patients with severe injuries or post-operative conditions, they are usually sedated for pain relief or mental stress management. For example, during ventilation, the patient must be physically calm to receive oxygen, which requires sedation. As a result, over-sedation and under-sedation are frequent occurrences that negatively impact patients’ health (Jackson et al., 2009). Furthermore, the flaws in the sedation process might be specifically detrimental in specific healthcare areas. For instance, post-cardiac surgeries in ICUs require the proper sedation due to the possibility of hemodynamic instability, lengthened mechanical ventilation, and ventilator-associated pneumonia (Alavi et al., 2020). The potential contingencies significantly increase the health risks and prolong the periods of stay in ICUs (Alavi et al., 2020). Therefore, it is essential to develop additional methods to improve the quality of sedation in ICUs.
From these considerations, BIS monitors might be highly effective as an additional tool to evaluate the sedation state. This technology generally refers to the assessment system that measures the electroencephalographic signals from brain activity (Shetty et al., 2018). Consequently, this information, retrieved via electrodes connected to the patient’s forehead, is transformed into raw dimensionless numbers in the 0-100 range (Shetty et al., 2018). 100-90 is associated with anxiolysis measures, 80-70 implies moderate sedation, and 60-0 designates various phases of deep sedation (Franges, 2006). In other words, BIS monitoring allows clinicians to understand the current sedation level and mitigate the possibility of over-sedation and under-sedation.
BIS monitoring has become widely used as a tool for controlling sedation in ICU and neocritical care (NCCU) patients. A large number of patients in ICUs are supported by mechanical ventilation, which frequently requires additional sedatives to increase the subject’s comfort (Shetty et al., 2018). BIS assessment demonstrates good correlation indices with the subjective scale of sedation level – Ramsay Sedation Score (Paliwal et al., 2015). These findings validate the implementation of BIS monitoring for sedation in ICUs.
Consequently, BIS monitoring might also be utilized as an adjunct method of sedation assessment. The researchers concluded that patients at the ICU, NCCU, and those requiring neuroprotection in the form of barbiturates could be observed in a deep coma using BIS, which should be a “useful addition to patient care” (Yousefi-Banaem et al., 2020, p. 2). Neuro patients suffering from brain damage and vasospasm can particularly benefit from this method. Another advantage of BIS monitoring is the overall reduction of sedation costs. The studies demonstrate an approximately 18% reduction in sedation costs per patient since it is possible to avoid utilizing additional medications, such as lorazepam or propofol (Shetty et al., 2018). According to recent research, BIS monitoring is also a valuable method to target the necessary levels of sedation among COVID-19 patients (Rubulotta et al., 2020). Due to the objectivity of the method, BIS monitoring can be used to adjust the sedation and prevent self-inflicted lung injuries (Rubulotta et al., 2020). Ultimately, BIS monitoring is one of the most prominent and effective tools for evaluating the sedation levels in ICU patients.
Nevertheless, similar to most innovative methods in healthcare, there are some side effects of BIS monitoring, which clinicians should be informed about. For instance, Poole et al. (2020) proved that the use of the bispectral index to monitor the brain frequencies of patients and measure the level of sedation could reduce the sedation effect. Consequently, Pappal et al. (2020) emphasize that reduction in sedation due to the use of BIS monitors can be dangerous, as it is “one of the direst complications for patients undergoing general anesthesia, and can lead to post-traumatic stress disorder in 70% of patients experiencing it” (p. 1). Ultimately, BIS monitoring is an effective tool; however, preliminary education and training are required to improve the overall understanding of the system among the staff members, thus, indicating the objectives of the current project.
Overarching Goal
The goal of this project is to implement the utilization of BIS monitors to effectively evaluate adequate sedation of patients in the ICU.
Project Objectives
Project Methods
Design
This project suggests the implementation of a pretest-posttest design aiming to evaluate the provider’s knowledge, as well as the quality and efficiency of BIS monitoring utilization. A simple questionnaire will be developed for the respondents to make a self-evaluation of their knowledge of the BIS technology. Furthermore, periodical visits and inventory checks will be used to assess the utilization of BIS monitoring. In case of considerably low results reported, a repeated educational session will be held. Should the outcomes be satisfactory, the educational program will be set and presented in future training. The Likert scale will be used to meet Objective #5 and evaluate the provider’s utilization of BIS monitors. A translational framework is suggested as an essential means of utilizing scientific and educational practice to improve public health outcomes (Stafford‐Brizard et al., 2017). In particular, the framework involves the following stages: research synthesis, BIS monitoring optimal use testing, educational session effectiveness testing, risk assessment, effectiveness, and value analysis, change in economic, clinical, and population outcomes evaluation.
Project Plan
Inputs
To implement staff training, which will explain the specifics of working with BIS technology, the participation of the main stakeholders – hospital management and nursing staff – will be required. The project will be launched with the approval of the management, which will allocate monetary compensation following the size of the salary to the medical institution employees who will conduct the educational training and to those employees who will participate in it. Other inputs include time spent by the responsible nurse leaders for implementing the objectives through the determined measures.
Outputs
The program will undertake two training sessions regarding BIS monitors, spread the visual aid on BIS effects for nurses, evaluate the baseline knowledge of personnel regarding BIS, assess the baseline utilization of BIS, and evaluate BIS knowledge utilization after the training sessions.
Budget
Monetary compensation – depending on the salary of tutors and the staff members in the hospital.
Equipment acquisition (if necessary, on behalf of the hospital) – BIS monitors are approximately $6500, sensors with three or four electrodes $25.
Measures
As identified above, a questionnaire will be developed as a measure of the provider’s baseline knowledge of BIS. In a later stage of the project, the Likert scale will be utilized to assess the provider’s utilization of BIS post-educational sessions. Cronbach’s alpha will be used to evaluate the reliability of the questionnaire items, namely, how consistent and stable the provided results are. Furthermore, the Content Validity Ratio (CVR) will be applied to determine the content validity and the relevance of the measurement instrument’s items to the target construct.
Data Analysis
Data Analysis Plan
Two software programs will be used for statistical analysis. First, SPSS (Statistical Package for the Social Sciences) is widely used in programs, projects, and research to generate reports on human behavior. Since the assessment of knowledge and utilization of BIS involves studying the behavior of nurses in the workplace, this software can be a good solution. SPSS allows the creation of descriptive statistics, graphical display of results, parametric and non-parametric analysis, and includes the ability to develop scripts to automate the analysis.
The second software that works well for the project is R, which allows research in medicine, human behavior, and other areas. The program provides many plugins and toolkits compatible with many applications and aims to simplify data processing. An additional training session on working with the software will be held to work with R since this program requires knowledge of the basics of coding. R is widely recognized by academics and has a community that posts improvements and related plugins for the program to the web. At the same time, to assess the success of the assimilation of knowledge about BIS, Independent Samples T-Test will be used (Xu et al., 2017). This test allows comparing the results between two independent groups concerning the dependent variable.
Outcomes
The expected program outcomes include increased skills of BIS technology use in hospital staff and positive health outcomes in ICU patients. As research suggests, expected patients’ health outcomes can include reduced risks associated with over- and under-sedation and shorter periods of stay in ICUs (Rubulotta et al., 2020). As for demographics, the impact of the program on the medical personnel and ICU patients in the hospital of choice will be measured with the purpose of further replication of the project in other healthcare institutions. As a result of educational training and knowledge assessment, a report will be created, providing hospital management with a better perspective on implementing the practices involving BIS monitors. Administrators will also be able to evaluate the competencies of nurses concerning the framework and ensure the safety and health of patients using the acquired data. Furthermore, the students will improve their understanding of BIS monitors and learn how to apply their knowledge to mitigate any potential side effects of the system.
Plan for Sustainability
The project’s sustainability will be ensured by establishing guidelines for the re-implementation of the project. This document will be approved by management and sent to the archive of the hospital so that at any time, any health worker can access it. The guidelines will include a timeline, educational leaflets, and documents with the necessary steps to complete the project. The recommendations will also cover all the necessary measures for performing the pre-test and post-test evaluation of BIS knowledge.
Contingency Plan
The contingency plan will include three steps to replace the original plan in case of an emergency. If educational meetings cannot be held, training participants will receive printed materials and perform a series of educational tests to confirm their understanding of the use and knowledge of BIS. These tests replace a personal post-assessment of the employees’ success in understanding the underlying principles of BIS monitoring. Pretesting might also be completed online, which is the third step of the contingency plan.
Potential Impact on Practice and Potential Policy Implications
The potential impact of practice will include a change in the attitude of healthcare providers towards the implementation of the BIS framework and a better understanding of this practice. Furthermore, potential policy implications may feature the recurrence of educational sessions every six months. In this case, student nurses and graduates with little experience will also be educated concerning the functions of BIS monitoring and its relevance in ICUs.
Summary
Overall, the project provides a framework for the use of BIS monitors to evaluate adequate sedation of ICU patients effectively. A pretest-posttest design aims to evaluate the provider’s knowledge, as well as the quality and efficiency of BIS monitoring utilization. Combining observational and physiologic sedation assessment tools is paramount to clinicians and should include all assessment parameters when making patient determinations for treatment. Expected project outcomes include improved skills of BIS use in hospital staff and positive health outcomes in ICU patients such as shorter periods of stay and reduced risks associated with over- and undersedation. Ultimately, both management and nurses will significantly benefit from the educational sessions, and the project might significantly enhance the quality of healthcare services in ICUs provided by the participators.
References
Alavi, S. M., Babaee, T., Fard, M. Z., Tirgarfakheri, K., Bourghani-Farahani, E., Bakhshandeh, H. (2020). Bispectral index monitoring can be an effective method to assess sedation levels after open-heart surgery. Iranian Heart Journal, 22(1), 49-56.
Franges, E. Z. (2006). BIS monitoring. Nursing Critical Care, 1(5), 58-61.
Jackson, D. L., Proudfoot, C. W., Cann, K. F., & Walsh, T. S. (2009). The incidence of sub-optimal sedation in the ICU: A systematic review. Critical Care, 13(204). doi:10.1186/cc8212
Paliwal, B., Rai, P., Kamal, M., Singariya, G., Singhal, M., Gupta, P., Trivedi, T., & Chouhan, D. S. (2015). Comparison between dexmedetomidine and propofol with validation of bispectral index for sedation in mechanically ventilated intensive care patients. Journal of Clinical and Diagnostic Research, 9(7). doi:10.7860/jcdr/2015/14474.6258
Pappal, R. D., Roberts, B. W., Winkler, W., Yaegar, L. H., Stephens, R. J., & Fuller, B. M. (2020). Awareness and bispectral index (BIS) monitoring in mechanically ventilated patients in the emergency department and intensive care unit: a systematic review protocol. BMJ Open, 10(3), 1-10. doi:/10.1136/bmjopen-2019-034673
Poole, B. R., Reese, Z. A., Dechen, T., Tocci, N., Elsamadisi, P., Holland, S., & Stevens, J. P. (2020). Patient and care delivery characteristics associated with harm from neuromuscular blockade. Critical Care Explorations, 2(6), 1-10. doi:10.1097/CCE.0000000000000147
Rubulotta, F., Soliman-Aboumarie, H., Filbey, K., Geldner, G., Kuck, K., Ganau, M., & Hemmerling, T. M. (2020). Technologies to optimize the care of severe coronavirus disease 2019 patients for health care providers challenged by limited resources. Technology, Computing and Simulation. doi:10.1213/ane.0000000000004985
Shetty RM, Bellini A, Wijayatilake DS, Hamilton MA, Jain R, Karanth S, Namachivayam A. BIS monitoring versus clinical assessment for sedation in mechanically ventilated adults in the intensive care unit and its impact on clinical outcomes and resource utilization. Cochrane Database of Systematic Reviews, 2(CD011240). doi:10.1002/14651858.cd011240.pub2.
Stafford‐Brizard, K. B., Cantor, P., & Rose, L. T. (2017). Building the bridge between science and practice: Essential characteristics of a translational framework. Mind, Brain, and Education, 11(4), 155-165.
Xu, M., Fralick, D., Zheng, J. Z., Wang, B., Tu, X. M., & Feng, C. (2017). The differences and similarities between the two-sample t-test and paired t-test. Shanghai Archives of Psychiatry, 29(3), 184. doi:10.11919/j.issn.1002-0829.217070
Yousefi-Banaem, H., Goharani, R., Hajiesmaeili, M., Tafrishinejad, A., Zangi, M., Amirdosara, M., & Nashibi, M. (2020). A review of Bispectral Index Utility in Neurocritical care patients. Archives of Neuroscience, 7(3), 1-12. doi:10.5812/ans.96490
Zheng, J., Gao, Y., Xu, X., Kang, K., Liu, H., Wang, H., & Yu, K. (2018). Correlation of bispectral index and Richmond agitation sedation scale for evaluating sedation depth: a retrospective study. Journal of Thoracic Disease, 10(1), 190. doi:10.21037/jtd.2017.11.129