The COVID-19 pandemic posed unprecedented challenges to healthcare systems worldwide,
particularly in managing critically ill patients requiring mechanical ventilation
early in the pandemic. Surging patient volumes strained hospital resources and complicated
the implementation of standard-of-care intensive care unit (ICU) practices, including
sedation management. The objective of this study was to evaluate the impact of an
evidence-based ICU sedation bundle during the early COVID-19 pandemic. The bundle
was designed by a multi-disciplinary collaborative to reinforce best clinical practices
related to ICU sedation. The bundle was implemented prospectively with retrospective
analysis of electronic medical record data. The setting was the ICUs of a single-center
tertiary hospital. The patients were the ICU patients requiring mechanical ventilation
for confirmed COVID-19 between March and June 2020. A learning health collaborative
developed a sedation bundle encouraging goal-directed sedation and use of adjunctive
strategies to avoid excessive sedative administration. Implementation strategies included
structured in-service training, audit and feedback, and continuous improvement. Sedative
utilization and clinical outcomes were compared between patients admitted before and
after the sedation bundle implementation. Quasi-experimental interrupted time-series
analyses of pre and post intervention sedative utilization, hospital length of stay,
and number of days free of delirium, coma, or death in 21 days (as a quantitative
measure of encephalopathy burden). The analysis used the time duration between start
of the COVID-19 wave and ICU admission to identify a "breakpoint" indicating a change
in observed trends. A total of 183 patients (age 59.0 +/- 15.9 years) were included,
with 83 (45%) admitted before the intervention began. Benzodiazepine utilization increased
for patients admitted after the bundle implementation, while agents intended to reduce
benzodiazepine use showed no greater utilization. No "breakpoint" was identified to
suggest the bundle impacted any endpoint measure. However, increasing time between
COVID-19 wave start and ICU admission was associated with fewer delirium, coma, and
death-free days (beta = - 0.044 [95% CI - 0.085, - 0.003] days/wave day); more days
of benzodiazepine infusion (beta = 0.056 [95% CI 0.025, 0.088] days/wave day); and
a higher maximum benzodiazepine infusion rate (beta = 0.079 [95% CI 0.037, 0.120]
mg/h/wave day). The evidence-based practice bundle did not significantly alter sedation
utilization patterns during the first COVID-19 wave. Sedation practices deteriorated
and encephalopathy burden increased over time, highlighting that strategies to reinforce
clinical practices may be hindered under conditions of extreme healthcare system strain.
