177 Can an Electronic Health Record Order Set Improve Analgesia and Sedation in the Intubated Emergency Department Patient

Analgesia and sedation are important parts of post-intubation patient care in the emergency department (ED). Optimizing this care has been shown to decrease time to extubation, intensive care unit length of stay, delirium, and mortality. Our institution reviewed post-intubation analgesia and sedation due to multiple adverse events and it showed inconsistent physician practices in regards to post-intubation medication administration. The goal of this study was to determine the effect of a standardized electronic health record (EHR) order set on post-intubation medication choices in the ED. This was a retrospective chart review of intubated ED patients at an urban, academic ED with an annual census of 64,000 visits. ED patients undergoing out-of-hospital or ED intubation were included from 03/01/2014 - 10/01/2015. An order set was created in the EHR (Epic Systems©) which defaulted to weight-based dosing of fentanyl and propofol or versed depending on the clinical scenario. Pre-populated bolus dosing and titration of infusion rates were determined by numeric pain and RASS scores. Use of the order set was at the discretion of the emergency physician. Physicians and nurses were educated regarding availability of the order set and on appropriate titration of medications prior to implementation. Utilizing a previously developed airway data registry of all intubated ED patients, a retrospective chart review was completed. Post-intubation administration of analgesics and sedatives during 60-day periods at 1 year prior, 2 months after and 6 months after order set implementation were reviewed. Our primary outcome was comparison of appropriate post-intubation medication administration at 6 months after implementation of the order set versus one year prior to implementation. The secondary outcome measured was utilization of the order set. We defined appropriate post-intubation medications as narcotic analgesics and an sedative agent including benzodiazepines, barbiturates or ketamine. Results with 95% CI are reported. Fishers exact test was used for statistical analysis. A total of 119 patients met inclusion criteria for this study (31 pre-intervention, 87 post-intervention). In the pre-intervention group, appropriate analgesia and sedation was ordered in 48.4% (15/31; 95% CI, 32-65%) of cases. Post-intervention, appropriate analgesia and sedation administration was significantly higher in the first 2 months at 88.9% (40/45; 95% CI, 79.7-98.1%) which was sustained at 6 months after implementation at 88.1% (37/42; 95% CI, 78.3-97.9%).The EHR order set was used in 75.6% (34/45) of cases 2 months after implementation and was sustained at 76.2% (32/42) of cases 6 months after implementation. Utilization of an EHR order set for post-intubation care was associated with higher rates of appropriate analgesia and sedation administration that was sustained six months after implementation in intubated ED patients.