Implementing the WAT-1: an 11 item withdrawal assessment tool

Transcription

1 Implementing the WAT-1: an 11 item withdrawal assessment tool M Woodard 1, F Gill 1,2, L Monterosso 2 1 Princess Margaret Hospital, Perth, Australia 2 Curtin University, Perth, Australia

2 Introduction Optimal analgesia and sedation of ventilated children is a well recognised management strategy in many PICUs 1 The side-effects of prolonged use (>5 days) and/or abrupt cessation may lead to iatrogenic withdrawal syndrome (IWS) 2 Withdrawal symptoms are often overlapping, difficult to isolate from underlying pathophysiological processes and most importantly are distressing for family members and caregivers to witness 3,4 There remains little consensus on the classification of withdrawal symptoms and therefore the most reliable tool to assess them 5 The use of a standardised assessment tool would provide the framework for systematic patient assessment, assist in early diagnosis of IWS, and evaluate effectiveness of treatment 6,7 The WAT-1 was selected for this project due to reported high validity in intensity ratings (94%), high sensitivity (87%) and specificity (88%) of withdrawal severity in children 7

3 Design Aim The purpose of this project was to introduce a change of practice, utilising the WAT-1, and thereby standardising the assessment of PICU patients identified as being at risk of developing withdrawal syndrome from prolonged use of and / or abrupt cessation of analgesia and sedative medications. Design Prospective quality improvement to change current practice comprising 2 phases: 1. Education on the use of WAT-1 tool & test inter-rater reliability 2. Implement tool & audit compliance/acceptance Setting 10 bed level III PICU situated in 250 bed major paediatric referral centre in 2009, n=46 (6%) of all admissions were ventilated > 5 days and were therefore at risk of developing IWS Sample All PICU nursing staff (n=46) & convenience sample of relief RNs (n=14)

4 Results 8 nursing staff attended 3 lecture style WAT-1 training sessions 28 nursing staff received opportunistic education at the bedside In total, 78% nursing staff & n=8 relief staff were trained in the use of the WAT-1 A total of 23 nursing staff participated in paired WAT-1 assessments on 4 patients identified as being at risk of developing IWS Nursing staff participating in paired WAT-1 assessments Designation Mean years of Paed Exp. Mean years of PICU Exp. Previous use of a withdrawal assessment tool Yes No CNs (n=8) 19 (3-30) 15.1 (3-24) 37% 63% RNs (n=14) 7.4 (4-14) 4 (0.5-10) 43% 57% Relief RNs (n=2) (1.5-20) 5.25 (0.5-10) 0 100%

5 Results Cohen s Kappa results for all 11 items of the WAT-1 Information from chart record, pervious 12 hours Kappa Statistic p estimate Strength of agreement Any loose/watery stools <.001 Substantial Any vomiting/wretching gagging <.001 Moderate Modal temperature > 37.8 o C <.001 Perfect State (SBS score) <.001 Perfect Tremor a NC Perfect b Any Sweating a NC Perfect b Uncoordinated/repetitive movement <.001 Substantial Yawning or sneezing NC Perfect b Startle to touch a NC Substantial b Muscle tone <.001 Perfect Time to gain calm state <.001 Substantial Total <.001 moderate Note. NC=not calculated and is due to insufficient variables for cross-tabulation a unable to calculate κ as no symptom variability observed. b Assumed perfect agreement as both groups agreed symptom not present

6 Results Demographic characteristics of patients identified as at risk of IWS who participated in paired assessments Patient 1 Patient 2 Patient 3 Patient 4 Age 9 years 14 years 7 weeks 10 years Sex Male Male Female Male Diagnosis category Sepsis (arthritis) Volvulus Cardiomyopathy Sepsis (sacro ileitis) Analgesic drugs Morphine Ketamine Fentanyl Morphine Morphine Morphine Fentanyl ketamine Sedative drugs Midazolam Midazolam Midazolam Midazolam Chloral hydrate Total length of time of analgesia &/or sedation 8 days (192 hours) 6 days (137 hours) 10 days (240 hours) 12 days (288 hours) Total ventilation time 105 hours 108 hours 241 hours 189 hours LOS in PICU 8 days 5 days 13 days 14 days

7 Results Mean duration of opioids was 9.25 days ± 2.75 SD days Cumulative average dose (morphine equivalents) delivered was 6.16 mg/kg ± 9.55 kg/kg SD Mean duration of midazolam was 7 days ± 3.0 SD Cumulative average dose delivered was mg/kg ± mg/kg SD Daily cumulative opioid dose (morphine equivalents mg/kg/day) Daily cumulative midazolam dose (mg/kg/day) 7 7 Opioid dose (mg/kg/day) Patient 1 Patient 2 Patient 3 Patient 4 Midazolam dose (mg/kg/day) Patient 1 Pateint 2 Patient 3 Patient Day No in PICU Day No in PICU

8 Discussion κ > on all 11 items indicated substantial strength of agreement κ was unable to be calculated for presence of tremor, sweating, yawning or sneezing and startle, due to insufficient variables Overall, the WAT-1 demonstrated good agreement Future education of the WAT-1 will be guided toward weaker inter-rater agreement sections Completion of documentation > 80% of occasions indicated acceptance of the WAT-1 1 infant was observed to have altered sleep patterns and a hyperactive Moro reflex, both reported symptoms of IWS, however are not incorporated in the WAT-1 The WAT-1 score for 1 child indicated IWS, however, the observed symptoms were likely the result of hunger Conclusion IWS is a common complication of prolonged use of analgesia &/or sedation2,5,7 The WAT-1 has demonstrated strong validity, sensitivity and specificity7 The WAT-1 has been accepted into current practice at our institution The tool has demonstrated substantial agreement between nursing staff with a wide range of experience

9 References 1. Anand KJS. Analgesia and sedation for ventilated children and infants. Respiratory Care. 1998; 43(11): Birchley G. Opioid and benzodiazepine withdrawal syndromes in the paediatric intensive care unit: a review of recent literature. Nursing in Critical Care. 2009; 14(1): Twite MD, Rashid A, Zuk J, Friesen RH. Sedation, analgesia, and neuromuscular blockade in the pediatric intensive care unit: survey of fellowship training programs. Pediatric Critical Care Medicine: A Journal Of The Society Of Critical Care Medicine And The World Federation Of Pediatric Intensive And Critical Care Societies. 2004; 5(6): Colville G, Kerry S, Pierce C. Children's factual and delusional memories of intensive care. American Journal Of Respiratory And Critical Care Medicine. 2008; 177(9): Ista E, van Dijk M, Gamel C, Tibboel D, de Hoog M. Withdrawal symptoms in children after longterm administration of sedatives and/or analgesics: a literature review. "Assessment remains troublesome". Intensive Care Medicine. 2007; 33(8): Anand KJS, Willson DF, Berger J, Harrison R, Meert KL, Zimmerman J, et al. Tolerance and Withdrawal From Prolonged Opioid Use in Critically Ill Children. Pediatrics. 2010; 125(5):e Franck LS, Harris SK, Soetenga DJ, Amling JK, Curley MAQ. The Withdrawal Assessment Tool- 1 (WAT-1): an assessment instrument for monitoring opioid and benzodiazepine withdrawal symptoms in pediatric patients. Pediatric Critical Care Medicine. 2008; 9(6):