New research from the Montefiore Einstein Department of Anesthesiology shows that treating critically ill patients with a multimodal, symptom-focused strategy (rather than deep sedation) is associated with better outcomes.

The study, titled “The association of medication-induced sedation and emotional distress during mechanical ventilation with adverse discharge: an observational cohort study,” was recently published in The Lancet Respiratory Medicine and represents the first peer-reviewed paper demonstrating the harmful impact of deep sedation on adverse discharge for patients who received mechanical ventilation while being treated in the intensive care unit (ICU).

Researchers in the Department of Anesthesiology’s Digital Health Laboratory analyzed data from more than 10,000 patients who were mechanically ventilated for 24 hours or more across 20 intensive care units within Montefiore Health System. The results support the need to reduce deep sedation utilization, which is already underway at Montefiore Einstein, led by a multidisciplinary team including the departments of Anesthesiology, Medicine, and Rehabilitation Medicine, as well as nursing, physical therapy, and respiratory therapy teams.

Led by Department of Anesthesiology Chair Dr. Matthias Eikermann and attending anesthesiologist Dr. Karuna Wongtangman, first author on the paper, the researchers found that patients who had a high proportion of deep sedation, defined as 75 percent of total ICU stay, had a higher risk of adverse discharge, or losing their ability to live independently. Dr. Wongtangman explained that deeply sedating patients who are mechanically ventilated can mask symptoms of pain and emotional distress while limiting patients’ mobility.

“If a patient is heavily sedated, it means they are not awake and not moving, which is not helpful for the recovery process,” Dr. Wongtangman said. “The recovery process is, of course painful, so we want to make sure we are treating patients’ pain without heavily sedating them. When a critically ill patient receives symptom control treatment for pain or emotional distress, for example, they can communicate with the patient care team, and we can more effectively evaluate and treat the patient.”

The benefits of patient-centered, symptom control treatment were evident in this study, as the researchers found that patients who had a high proportion of emotional distress had a lower risk of adverse discharge. Instead of patients’ emotional distress being masked by sedation, providers were able to more comprehensively evaluate these patients, recognize symptoms of emotional distress, and treat them accordingly with antipsychotics or non-opioid analgesics, for example.

In addition, significantly more patients who were deeply sedated did not receive active mobilization therapy while they were mechanically ventilated. The absence of mobilization therapy was a key driver of patients losing the ability to live independently after hospital discharge. To encourage a culture shift toward increased early mobilization in the ICUs, Drs. Eikermann and Wongtangman have spearheaded the creation of a system-wide Mobilization Committee. This multidisciplinary group will conduct “mobilization rounds” in Montefiore Einstein’s ICUs to identify barriers to early mobilization and develop strategies to address them.

“With the help of a new Epic-integrated digital patient board, the patient care team is now discussing mobilization achievements, goals, and barriers for each patient using evidence-based measures like the Johns Hopkins Highest Level of Mobility,” Dr. Eikermann explained. “Similarly, we are now formally evaluating goal versus achieved sedation levels in our mechanically ventilated patients using the Richmond Agitation-Sedation Scale (RASS). Importantly, we are using this digital patient board not only during the day shift, but also during the night shift when sedation is frequently deepened even though our goal remains light or no sedation.”

The study analyses showed that, based on RASS measurements, patients received deep sedation at a rate three times higher than was initially ordered by a physician or nurse practitioner. Researchers observed that the highest levels of sedative doses were administered during the evening hours. Uncovering this trend has led the Anesthesiology Critical Care Medicine team to develop a comprehensive Surgical ICU Order Set so that all providers are aware of the negative impacts of deep sedation and have the tools needed for alternate treatment of pain, agitation, and insomnia, for example.

Data for the study was made available through the Digital Health Laboratory’s ICU Database, developed by attending anesthesiologist and intensivist Dr. Michael Kiyatkin, director of the Post-Anesthesia Care Unit. With access to granular data from a large cohort of patients, the researchers were able to test their hypotheses on the impact of deep sedation.

Dr. Kiyatkin explained that, in addition to revising clinical practice to reflect best practices demonstrated in this study, there has been an additional effort at Montefiore to align Critical Care Medicine with the 4Ms of Age-Friendly Care: What Matters, Medication, Mentation, and Mobility. The Age-Friendly Hospital Measure was recently implemented by the Centers for Medicare & Medicaid Services (CMS) with the goal of improving quality of care for older patients throughout the United States.

“A lot of interests have aligned including 4M, the study published in The Lancet Respiratory Medicine, and the Montefiore Health System Mobilization Committee,” Dr. Kiyatkin reflected. “Many things are coming together like a puzzle. This is an exciting time to get the issue of adverse discharge solved, focusing on mobilization and sedation.”

The Department of Anesthesiology’s multidisciplinary collaboration is reflected in the study through the contributions of the ICU Sedation Collaborators. This group is comprised of Senior Vice President and Chief Nursing Executive Maureen Scanlan, Clinical Pharmacy Manager for Critical Care Dr. Pooja Kumar, members of the Department of Medicine Critical Care Division, surgeons, and pulmonary critical care physicians. This interdisciplinary team was built to integrate the innovative findings of this study into a new strategy to provide better care tomorrow for Montefiore Einstein patients.

The work for this study grew out of an article published by Dr. Eikermann in The Lancet Respiratory Medicine in 2023. This article, titled “Multimodal, patient-centred symptom control: a strategy to replace sedation in the ICU,” was co-authored by renowned intensivists Dr. Dale Needham, medical director of the Critical Care Physical Medicine and Rehabilitation Program at Johns Hopkins Medicine, and Dr. John Devlin, associate scientist in the Division of Pulmonary and Critical Care Medicine at Brigham and Women’s Hospital. The 2023 paper provides recommendations for both pharmacological and non-pharmacological strategies for reducing reliance on sedation in the ICU to improve patient outcomes. Now, the most recent observational study provides the evidence needed to implement these strategies in clinical practice.

“Our data published in this investigation will fuel future quality improvement work to allow renewed efforts at implementation and adherence to evidence-based guidelines for treating critically ill patients,” Dr. Eikermann said.

“The goal is to improve patients’ outcomes with higher survival rates, shorter lengths of stay, a return to independent living, and faster recovery to the lives they want to live with their loved ones.”