Will Adequate Sedation Assessment Include the Use of Actigraphy in the Future?

The current challenges of oversedation and undersedation leave healthcare personnel looking for more answers. Oversedation is cost prohibitive in the 21st century. With the shortage of nurses and healthcare dollars, care providers are evaluating methods to continuously improve care, lower costs, and decrease overall length of stay. Oversedation can have detrimental effects on patients and their families, particularly when a loved one is unarousable and needs unwarranted diagnostic testing. Unnecessary tests are costly in dollars, as well as in nursing time and care. How many times have you brought a patient for computed tomography of the head because of unresponsiveness, only to find out that the patient’s neurological findings are not abnormal? After the sigh of relief, we ask ourselves if we could have prevented this unnecessary procedure. In the past several years, hospital budgets and subsequent reimbursement have decreased, making everyone much more cost conscious. Although oversedation may make it “easier” to care for our patients, undersedation of patients may lead to added stress and agitation among patients, unanticipated removal of vascular access devices and tubes by patients, patients’ recall of therapeutic paralysis, and potential injuries to healthcare providers. It is no surprise that 92% of critically ill patients require sedatives and analgesics. It is generally accepted that an analysis of the root causes of agitation would yield many explanations for the behavior. Agitation develops in nearly 71% of patients during the intensive care unit stay as a result of impaired sleep cycles, delirium, pain, and so on. Most of these conditions are easily treatable; however, subtle cues of agitated behavior are easily overlooked. With the reduction in the number of inpatient beds, the shortage in nursing personnel, and the increasing costs of pharmaceutical agents, a multidisciplinary approach to assessment of sedation must be taken. Historically, vital signs were used to determine the level of sedation in critically ill patients. Because many factors can alter vital signs, this approach is severely limiting. Recently, the Society of Critical Care Medicine and the American Society of HealthSystem Pharmacists revised the clinical practice guidelines for sedation and analgesia. This group of specialists reviewed peer-reviewed research literature from 1994 through 2001. On the basis of the clinimetric properties of the research studies, new guidelines were proposed. Healthcare providers are urged to use a recommended sedation scale, develop an individualized sedation goal for each patient, evaluate the goal frequently, and redefine the goal as necessary. Although the Ramsay Sedation Scale has gained wide acceptance in the past several decades, it has not been recommended for assessing critically ill patients. The Ramsay scale is a 6-point scale that includes scores for 3 awake states and 3 asleep states. It does not address the issue of agitation. The Sedation Agitation Scale, developed by Richard Riker, combines a sedation continuum with assessment of agitation. This 7-point scale includes descriptors and behaviors to assist bedside practitioners with correct scoring. The Motor Activity Awareness Scale, a derivative of the Sedation Agitation Scale, is 7point scale that includes clarified descriptors in which “and” or “or” are used to describe behavior. Both of these scales have good clinimetric properties, are easy to administer, and do not require a lengthy assessment. The Vancouver Interaction and Calmness Scale is also recommended in the practice guidelines. This tool is actually 2 independent scales in one. The first scale is used to evaluate a patient’s interactions and communication; the second scale is used to evaluate the degree of calmness or restlessness. Each of the assessment scores can range from 5 to 30. The target score for this tool has not been clearly defined.