Challenges and barriers to optimising sedation in intensive care: a qualitative study in eight Scottish intensive care units

Kalliopi Kydonaki, Janet Hanley, Guro Huby, Jean Antonelli, Timothy Simon Walsh, Development and Evaluation of Strategies to Improve Sedation practice in inTensive care (DESIST) study investigators, Alasdair Hay, Fiona Pollock, Louise Boardman, Corrienne Mcculloch, Heidi Dawson, David Hope, Kallirroi Kefala, Michael Gillies, Louise Bell, Deborah Rodgers, Sue Wright, Kirsty Everingham, Emma Phillips, John Rutherford, Dr Dewi Williams, Catherine Jardine, Tara Quasim, Alex Puxty, Steven Henderson, Naomi Hickey, Elizabeth Lennon, Jane Ireland, Natalie Dickinson, Marie Callaghan, Dominic Rimmer, Alan Davidson, Katherine Mcguigan, Anissa Benchiheub, Laura Rooney, Jonathan Richards, Janice Grant, Pamela Scott, Marianne Mallice, Marcia Mcdougall, Claire Mcginn, Sarah Gray, Keith Boath, Louise Doig, Lesley Berry, Edward Greenwood, Elish Daglish, Carolyne Bullions, Elaine Black, Donna Beattie, Elaine Paton, Alison Connelly, Nancy Hudson, Neville Tomkins, Julia Cook, Terry Hughes, Lynne Cairns, Jennifer Rowe, Ben Slater, Susan Russell, Bob Savage, Gavin Simpson, Ben Shippey, Stephen Cole, Louise Cabrelli, Jackie Duffy, Pauline Amory, James Ruddy, Margaret Harkins, Elizabeth Reaney, Lyndsey Kearney, Angela Hamill, Isobel Paterson, Ronald Harkess, Samantha Thomas, Christopher Weir, Robert Lee, Jacqueline Stephens, Petra Peltola, Kimmo Uutela, Lasse Kamppari, Mika Sarkela, Christine Blaydon, Shaun Mcwhinnie, Danny Mcauley, John Norrie, Stephen Wright, Kalliopi Kydonaki, Janet Hanley, Guro Huby, Jean Antonelli, Timothy Simon Walsh, Development and Evaluation of Strategies to Improve Sedation practice in inTensive care (DESIST) study investigators, Alasdair Hay, Fiona Pollock, Louise Boardman, Corrienne Mcculloch, Heidi Dawson, David Hope, Kallirroi Kefala, Michael Gillies, Louise Bell, Deborah Rodgers, Sue Wright, Kirsty Everingham, Emma Phillips, John Rutherford, Dr Dewi Williams, Catherine Jardine, Tara Quasim, Alex Puxty, Steven Henderson, Naomi Hickey, Elizabeth Lennon, Jane Ireland, Natalie Dickinson, Marie Callaghan, Dominic Rimmer, Alan Davidson, Katherine Mcguigan, Anissa Benchiheub, Laura Rooney, Jonathan Richards, Janice Grant, Pamela Scott, Marianne Mallice, Marcia Mcdougall, Claire Mcginn, Sarah Gray, Keith Boath, Louise Doig, Lesley Berry, Edward Greenwood, Elish Daglish, Carolyne Bullions, Elaine Black, Donna Beattie, Elaine Paton, Alison Connelly, Nancy Hudson, Neville Tomkins, Julia Cook, Terry Hughes, Lynne Cairns, Jennifer Rowe, Ben Slater, Susan Russell, Bob Savage, Gavin Simpson, Ben Shippey, Stephen Cole, Louise Cabrelli, Jackie Duffy, Pauline Amory, James Ruddy, Margaret Harkins, Elizabeth Reaney, Lyndsey Kearney, Angela Hamill, Isobel Paterson, Ronald Harkess, Samantha Thomas, Christopher Weir, Robert Lee, Jacqueline Stephens, Petra Peltola, Kimmo Uutela, Lasse Kamppari, Mika Sarkela, Christine Blaydon, Shaun Mcwhinnie, Danny Mcauley, John Norrie, Stephen Wright

Abstract

Objectives: Various strategies to promote light sedation are highly recommended in recent guidelines, as deep sedation is associated with suboptimum patient outcomes. Yet, the challenges met by clinicians in delivering high-quality analgosedation is rarely addressed. As part of the evaluation of a cluster-randomised quality improvement trial in eight Scottish intensive care units (ICUs), we aimed to understand the challenges to optimising sedation in the Scottish ICU settings prior to the trial. This article reports on the findings.

Design: A qualitative exploratory design: We conducted focus groups (FG) with clinicians during the preintervention period. Setting and participants: Eight Scottish ICUs. Nurses, physiotherapists and doctors working in each ICU volunteered to participate. FG were recorded and verbatim transcribed and inserted in NVivo V.10 for analysis. Qualitative thematic analysis was undertaken to develop emergent themes from the patterns identified in relation to sedation practice. Ethical approval was secured by Scotland A Research ethics committee.

Results: Three themes emerged from the inductive analysis: (a) a recent shift in sedation practice, (b) uncertainty in decision-making and (c) system-level factors including the ICU environment, organisational factors and educational gaps. Clinicians were challenged daily to manage agitated or difficult-to-sedate patients in the era of a progressive mantra of 'just sedate less' imposed by the pain-agitation-delirium guidelines.

Conclusions: The current implementation of guidelines does not support behaviour change strategies to allow a patient-focused approach to sedation management, which obstructs optimum sedation-analgesia management. Recognition of the various challenges when mandating less sedation needs to be considered and novel sedation-analgesia strategies should allow a system-level approach to improve sedation-analgesia quality.

Desist registration number: NCT01634451.

Keywords: qualitative research; quality In health care.

Conflict of interest statement

Competing interests: GE Healthcare partly funded the DESIST study, as unrestricted support, but had no control over research design, data analysis or interpretation, manuscript writing or the decision to publish this study.

© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Figures

Figure 1
Figure 1
Themes derived from the FGs. Sedation–analgesia practice, in oval, is the principal topic. The main barriers to optimum sedation–analgesia practice are presented in circles with explanatory information in the arrow boxes, and within a pie shape border to symbolise their obstructive role –. FG, focus groups; ICU, intensive care unit.

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