Reducing Iatrogenic Opiate Withdrawal in the PICU: An Evidence-based Practice Improvement Project

BACKGROUND: Current recommendations to reduce pain associated with mechanical ventilation is the administration of opiate and benzodiazepine infusions for Pediatric Intensive Care Unit (PICU) patients. If these infusions are weaned too quickly, iatrogenic withdrawal syndrome (IWS) often occurs. IWS symptoms include tachycardia, hypertension, diaphoresis, fever, irritability, tremors, clonus, hyperactive reflexes, vomiting, and diarrhea. Untreated IWS can lead to life-threatening complications.
LOCAL PROBLEM: The PICU at the project site contains fourteen beds and treats critically-ill pediatric patients. There was no standardized withdrawal assessment tool in practice. The purpose of this project was to implement the Withdrawal Assessment Tool-Version 1 (WAT-1) in the PICU to shorten the length of stay (LOS) and decrease IWS.
METHODS: This project was guided by the Evidence-based Practice Improvement Model, a design that incorporates both evidence-based practice and quality improvement. The PICU nurses were educated on the WAT-1 and scored appropriate patients every twelve hours. Data was collected for three months pre- and post-implementation.
INTERVENTIONS: The PICU nurses were educated on the use of the WAT-1 and scored appropriate patients every twelve hours. The average PICU LOS was analyzed to determine any difference after implementation.
RESULTS: Implementation of the WAT-1 in the PICU at the project site did not result in a statistically significant decrease in LOS, however, the average length of stay decreased by 1.5 days. The majority of PICU patients during the implementation period were less than two years old and had a respiratory diagnosis.
CONCLUSIONS: The use of the WAT-1 in the PICU demonstrated a 1.5 day decrease in the average PICU LOS. The implementation of a standardized withdrawal assessment tool is recommended by the Society of Critical Care Medicine. This project is sustainable after implementation into the electronic health record. The implementation of the WAT-1 allows for future development of a standardized methadone weaning protocol based on patient scores.