This is the first multicenter project that aims to improve analgosedation monitoring in Spanish PICUs. Our study shows that a specific training project significantly improves analgesia, sedation and withdrawal monitoring. It enhances awareness of health professionals and facilitates the creation of analgosedation working teams consisting of doctors and nurses. This leads to regular and long-term monitoring after the educational intervention. Our project could be a model for the development of new similar projects in other countries.
In the second survey, conducted five years after the intervention, it is important to highlight the improvement in the daily monitoring of analgosedation, withdrawal and delirium. Creation of multidisciplinary working teams (doctors and nurses), and a better follow-up of the recommendations to homogenize the use of clinical scales in the Spanish PICUs had significantly increased too. Furthermore, the use of COMFORT/COMFORT-b scale (specific for pediatric patients) raised compared to Ramsay scale, which is only validated for adults (10, 11).
The analysis showed that over the 2 months of data collection, analgosedation monitoring followed the international recommendations. The implementation of analgesia scales per shift achieved good pain control. Based on an early diagnosis and treatment adjustment according to the score, most of the patients showed no pain or mild pain, and an appropriate level of sedation (4).
The second survey, conducted five years after the intervention, showed an improvement of analgosedation monitoring in both the M and non-M group, which reflected a growing awareness of PICU health professionals of the importance of this monitoring (12, 13). We think that there could have been a contagion or spread effect from the PICUs included in the MONISEDA project to the rest of Spanish PICUs (14, 15).
Other studies have previously highlighted the importance of an appropriate AS monitoring in order to prevent and manage the appearance of withdrawal syndrome or delirium (16–18).
Achieving an improvement on AS and withdrawal monitoring in the Spanish PICUs is challenging. The implementation of a new routine in a clinical service is difficult, especially when it is a highly complex unit and there is a high staff turnover. Both time and a great effort are essential to accomplish this task. Difficulties to introduce these types of protocols are mentioned in other studies (19, 20). We consider that the creation of working teams made up of doctors and nurses is very important. The engagement and training of the nursing staff is crucial as they are in charge of the AS monitoring and the adjustment of the treatment to the patient´s condition (16). However, despite the observed improvement in 2020 survey, there are still some aspects, as the withdrawal and delirium monitoring (16, 21, 22) which need to be enhanced and that require continuous evaluation and feedback.
Our study has some limitations. Despite that every Spanish PICU was invited to participate in the project, only one third of them accepted. So, probably, those PICUs included in the project were also those with higher awareness of the importance of analgosedation and those that felt the need to implement these protocols. This concern could have introduced a bias in the comparison of both groups and could explain the fact that in the initial survey only a small percentage of PICUs followed a written AS protocol. Another limitation is that the observational study of patients was not repeated in 2020 to verify the improvements observed in the survey in the daily practice.