ICU Sedation Management Checklist

High Risk—High Alert Medications
 Is the patient's RASS goal appropriate for his/her current condition?
Name two High Alert Medications on your Unit?
 Are the RASS goals updated on EACH medication?
Examples: Insulin, Heparin (make sure they apply to your unit)
 If the RASS assessment doesn't match the current RASS goal, are you Why are they High Alert Medications on your Unit?
intervening? Example: Insulin
 Is the patient appropriate for a Daily Sedation Interruption (DSI)/  Narrow Therapeutic Range– small changes in dose may lead to side effects.
Sedation Awakening Trial (SAT)?  Multiple kinds of insulin– look alike, sound alike.
 Have you performed and documented the DSI/SAT? Example: Heparin
 Pass or fail?  Narrow Therapeutic Range
 If the patient passed the DSI/SAT, did you restart the continuous se-  Complex dosing that may lead to adverse effects.
dation at 50% of the rate? What are some safe guards in place with these High Alert Medications?
 Does your documentation reflect sedation rate titration? Examples:
 Have you completed and documented the CAM-ICU appropriately?  Insulin & Heparin: independently checked by two licensed caregivers prior to ad-
Timeline of improvements: ministration.

 Sedation Bundle Implementation started several years ago
 Nursing and Pharmacist re– education 2015-2016
 PowerPlan updates 2015-2016 (analagosedation approach to orders)
 Daily MDR sedation data collection started in Fall 2016
 Great Progress so far! Improved compliance with DSI/SAT; Improved compliance
with policy regarding restart of sedation med at ½ rate; Decrease in overall sedative
use – therefore decrease in side effects, delirium, etc.
**Pharmacists should be able to speak to MDR data collection happening
daily**
Reference: PCS Intensive Care Units Policy—Daily Sedation Interruption (DSI) or
Spontaneous Awakening Trial (SAT)
OR and Procedural Areas:
 Confirm Warmer Temperature documentation (see warmer policy)
 Confirm syringes and multi-dose vials are properly labeled
 Syringes: labeled with med name, strength, amount of medication or
amount of solution containing medication, beyond use date and time
 Multi-dose vials: labeled with beyond use date of 28 days
Reference:
Administrative Policy—Fluid Warmers—Medication Expiration
Administrative Policy– Medication Labeling in Perioperative and Other
Procedural Settings
 Tall Man Letters (Pyxis, PowerChart, Medication Labels): HumuLIN HumaLOG
 Insulin 500units/mL and long acting insulin (Insulin Glargine) are stocked in pharmacy
and dispensed unit dose per patient.
 Heparin cannot be overridden in Pyxis for removal; Heparin solutions are stored sepa-
rately from other IV solution. Heparin vials of different strengths are stored separately
in Pyxis.
Reference: Administrative Policy- High Risk High Alert Medications
**Posters have been hung by all Pyxis machines**
Medication Orders—PRN medications
Multiple Routes of Administration: Which medication to select?
Example: Hydromorphone 0.5 mg IV push Q3h, prn, pain – moderate
Hydrocodone/Acetaminophen 5 mg/325 mg 1 tab PO Q4h prn, pain – moderate
Key Decision Criteria:
1. Ascertain that all options are viable for the patient (i.e. Ability to swallow, level of conscious-
ness, presence of IV access, presence of nausea and vomiting).
2. The IM route is the least preferable for most medications due to patient discomfort and
fluctuations in absorption.
3. If rapid response is needed (i.e. severe pain level, new post-operative patient) consider
absorption time of IV versus oral administration.
4. Consider patient preference and effectiveness of previously administered doses.
Make sure to clarify any therapeutic duplications
(types of PRN orders: pain, antiemetic, constipation, etc)
Example:
Acetaminophen 650 mg/ 2 Tab PO Q4h PRN Pain-Mild/Fever greater than 100.4
Ibuprofen 600 mg/ 1 Tab PO Q6h PRN Pain - Mild
HYDROcodone/Acetaminophen 5 mg/325 mg 1 Tab PO Q4h PRN Pain - Moderate
HYDROmorphone 1 mg/ 1 mL IV Push Q4h PRN Pain - Severe

January 2019 
 

Medication Overrides in Pyxis:
Joint Commission Standard requires pharmacist review of all medica-
tion orders. Two exceptions are allowed:
(1) When a Licensed Independent Practitioner (LIP) controls the ordering, prepa-
ration, and administration of the medication
(2) When a delay would harm the patient in an urgent/emergency situation in-
cluding sudden changes in a patient’s clinical status
Reference: Pharmacy Policy: Automated Dispensing System- Medica-
tion Overrides
Verbal or Telephone Orders:
Verbal or telephone orders are to be limited and restricted to:
 Emergent situations
 When clinical situations make it impractical for orders to be entered into the
EHR or written on the appropriate form for the non-EHR sites.
 Situations when Practitioners do not have access to remote computer devices
or the patient’s chart.
Reference: Administrative Policy: Physician Orders
Palliative Ventilator Withdrawal (PVW) Policy
1. PVW Power Plan must be utilized
2. Practitioner must electronically enter their own PVW Power Plan orders
3. No verbal orders for PVW Power Plan
4. Medication dosing outside of Power Plan, or medications not included on
Power Plan, Practitioner must obtain approval per policy
5. Practitioner or RN cannot administer PVW medications until verified by phar-
macy
Reference: Patient Care Services Policy: Palliative Ventilator Withdrawal
Antimicrobial Stewardship Program
Goal: Decrease unnecessary and inappropriate use of antibiotics and
associated side effects of overuse, including antibiotic resistance
Patient Education:
Patient education regarding antibiotics is automatically included in discharge edu-
cation materials.
Regional Committee: Meets every other month and reports to P&T committee
annually
Performance Improvement (PI) Focus for 2018-2019:
(1) Fluroquinolone Days of Therapy, (2) Ertapenem Restriction Adherence
(3) Ceftaroline, Daptomycin Restriction
**AMS Pharmacists and ID Physicians should be able to speak to data in PI
Plan**
Reference: Administrative Policy—Antimicrobial Stewardship Policy
Pain Management Standards
New Joint Commission Standard in 2018
Pain Management policy—found in Administrative Policies & Procedures
 Pain management includes pharmacological and non-pharmacological interven-
tions, which is individualized based on the patient’s condition and goals for care
as well as his/her cultural, personal, and spiritual beliefs.
 Pain is assessed using one of the 5 following scales: (1) NIPS – Full term and
preterm infants to 1 year (2) Numeric Rating Scale (Adult) - Rated using a 0-10
numeric scale where “0” is no pain and “10” is the worst possible pain.
(3) FACES – Intended for children 4 – 16 years of age, older adults and those
who are mildly to moderately cognitively impaired (4) Pain Assessment in Ad-
vanced Dementia (PAINAD) – Intended for adults with moderate to advanced
dementia. (5) The Critical Care Pain Observation Tool (CPOT) – For verbal and
nonverbal adult intensive care unit patients. The four categories (facial expres-
sion, body movements, muscle tension, compliance with the ventilator) are
scored 0-2, which results in total score of 0-8.
 Patient education is provided at discharge for patients discharged with pain
medications.
 Annual pain management education for all colleagues through HealthStream
education modules - for 2019 Smart Rx education has been assigned to Phar-
macy, Nursing, and Physicians.
Medication Storage and Security
 All medications must be secured AT ALL TIMES
 Patient med bins/raspberry bins should be closed and locked, no medications in
your pocket, no medications on the counter or in the nursing station, no medica-
tions sitting in the tube station, etc.
What is the appropriate amount of time to waste a controlled substance?
Immediately or within 1 hr, document waste in Pyxis.
Where do you waste controlled substances?
Squirt or Flush to ensure irretrievability
 Fentanyl patches must be folded and flushed
 Injectable solutions squirt out into the sink or toilet (Examples: IVs,
PCAs, Hydromorphone)
 Oral and suppository drug content to be flushed—not crushed
What do you do if a patient brings in their own medications?
Should be sent home with family or given to safety and security for safe keeping. If
a patient requires use of home medication for their care it should be sent to the main
pharmacy for identification and to check integrity prior to administration.
Reference:
Pharmacy Policy—Controlled Substances-Schedule II – V; Pharmacy Policy—
Pharmaceutical Waste Disposal; PCS Policy –Medication Brought from Home
January 2019