Training from the Heart

Decreasing medication dependency in the cardiac ICU: Cardiac RESTORE

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crestore patient at Boston Children's Hospital

Children undergoing heart surgery need strong sedation and pain medications. Weaning them off these medications is complicated; many have withdrawal symptoms that require additional medications. Unfortunately, says Patricia Lincoln, RN, MS, CCRN, CNS-BC, “the medications we use to manage withdrawal may keep patients in the hospital longer.”

Last spring, Lincoln and her nursing colleagues in the Boston Children’s Hospital Cardiac Intensive Care Unit (CICU) launched an initiative called Cardiac RESTORE to help wean patients from pain and sedation medications according to a carefully designed algorithm.

“Cardiac RESTORE helps us continually assess what patients need and regulate their physiologic response to changes,” says Lincoln. “Medication doses are constantly being titrated or weaned unless the patient has an acute deterioration.”

Early results show decreased usage of pain and sedation medications with no ill effects.

Change the approach, not the medication

Cardiac RESTORE (cRESTORE for short) is based on work by Martha Curley, RN, PhD, FAAN, a nurse scientist in Boston Children’s cardiovascular and critical care programs. Curley had conducted a study of respiratory failure patients in more than 30 pediatric intensive care units (PICUS) across the United States and devised an algorithm for weaning them off sedation. With the algorithm in place, patients were exposed to fewer sedatives for shorter periods of time — a finding that spurred Lincoln and colleagues to adapt the algorithm for cardiac surgery.

cRESTORE categorizes patients based on the severity of their illness, signs of withdrawal and pain relief needs. Pain and sedation are measured with an established pediatric pain scale adapted for the child’s age. For example, infants and young children who are intubated are assessed at least every four hours on the State Behavioral Scale (SBS) (also developed by Curley) using these measures:

  1. Respiratory drive/ response to ventilation
  2. Coughing
  3. Best response to stimulation
  4. Attentiveness to care provider
  5. Tolerance to care
  6. Consolability
  7. Movement after consoled

Illness severity is broken into three phases: 1) the acute phase, in which the goal is to maintain the patient’s physiological stability; 2) the titration phase, in which the patient may be a little awake and medications are lowered by 10 percent every eight hours; 3) the waiting to extubate phase, in which medications are discontinued.

Unless a child’s condition worsens, medications are continuously lessened. If a nurse needs to give supplemental medications more than three times in an eight-hour period, the wean step is postponed.

Benefits of Cardiac RESTORE

Enrollment in the new program began in March 2015. By April, all cardiac surgery patients in the CICU and step-down unit were managed on cRESTORE, and 95 percent of the CICU nursing are trained in the algorithm. A smaller, more rigorously trained group of nurses make special rounds each day to check on patient progress.

So far, use of cRESTORE has indeed decreased the amount of pain and sedation medications patients are on — both on leaving the ICU and on leaving the hospital — with no increase in perceived pain or adverse outcomes.

Lincoln says that managing cardiac patients on cRESTORE has led to some important learnings. For example, some cardiac patients may need to be weaned a bit more slowly than respiratory patients (every twelve hours instead of every eight hours) because they’re less able to tolerate the fast heartbeat that comes with withdrawal.

Besides the obvious merits of avoiding withdrawal symptoms and decreasing the amounts of strong medications children need, Lincoln says there’s a more visible benefit to cRESTORE’s success.

“When patients are more awake, parents are able to interact with them more,” she says. “That’s been really nice to watch.”

*Risk adjusted based on data from the Society of Thoracic Surgeons

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