Why hospitals need to rethink the use of deep sedation

It’s clear that keeping patients on deep sedation can lead to more complications, researchers say.

Mari Armstrong-Hough of NYU School of Global Public Health, and Thomas Valley, MD, of the University of Michigan.

At the same time, hospitals are placing too many patients on ventilators in deep sedation for too long, researchers suggest. The problem is especially stark with Hispanic patients with respiratory failure, as they are five times more likely to be heavily sedated.

Researchers say they are troubled by the disparity in Hispanic patients, but they are also disappointed to see many patients on ventilators ending up in deep sedation for days. Researchers outlined their findings in a study published in the Annals of the American Thoracic Society.

“Hispanic patients were more likely than non-Hispanic patients to get deeply sedated. But the other important takeaway is that we're still deeply sedating everybody,” says Thomas Valley, MD, a co-author of the study and associate professor of pulmonary and critical care medicine at the University of Michigan. “We're just deeply sedating Hispanic patients even more so.

“So there's a lot of room for improvement for everybody, but particularly for Hispanic patients,” Valley tells Chief Healthcare Executive®.

Mari Armstrong-Hough, co-principal investigator of the study and assistant professor of social & behavioral sciences and epidemiology at the NYU School of Global Public Health, said in an interview that most were under deep sedation on the first day.

More than 90% of patients examined were in deep sedation at some point during their first five days on ventilators, and patients spent almost 75% of those days heavily sedated, researchers found.

“Some patients are being deeply sedated for longer and others are not,” Armstrong-Hough says.

The researchers analyzed 505 patients with moderate to severe acute respiratory distress syndrome (ARDS) at 48 hospitals around the country. The patients were on ventilators and light sedation was recommended, researchers said.

Patients that are placed under deep sedation can develop serious long-term problems, Valley notes. Over the past few decades, doctors and researchers have gained an understanding that deep sedation can lead to more serious complications, including delirium, weakness and death.

It’s not clear why so many people are being placed in deep sedation, the researchers said. They speculate that the high volume of Hispanic patients could be heavily sedated at least in part due to language barriers.

“There's a sort of vicious circle of when there's language discordance,” Armstrong-Hough says.

If the nurse or doctor can’t communicate with the patient, the patient could become more agitated, and that may be triggering the use of deep sedation in Hispanic patients.

“I would be agitated if I was in a situation where I was experiencing secondary language loss and I couldn't communicate with the nurse who was caring for me,” Armstrong-Hough says. “It certainly seems like this is something that might matter even beyond the issue of sedation delivery.”

Many hospitals and health systems have struggled with staffing, and researchers say that could be a factor in so many patients being placed in deep sedation. Valley says hospitals that were overwhelmed with patients during the COVID-19 pandemic may have had little choice but to keep some patients in heavy sedation.

“One of the reasons why we might use sedation is to keep a patient safe who's on a breathing machine,” Valley says. “We don't want them to rip out their tube when we're not looking.”

During the height of the COVID-19 pandemic, he says, “We were deeply sedating everybody because we didn't have enough nurses and physicians at the bedside. We were worried about people ripping out their tubes, to how long it would take to have to get back into the room to put it back in. Everybody got deeply sedated.”

Before the pandemic, hospitals were beginning to use deep sedation more sparingly. “And now we're just trying to dig ourselves back out and trying to get back to where we were,” he says.

Part of the issue requires a change in thinking when it comes to deep sedation, Valley says.

“It's a struggle now to get back to where we were before because we're so used to patients just looking good because they're deeply sedated,” Valley says.

The researchers said the hospitals examined were a representative group, and included some top-tier facilities that were placing too many patients in deep sedation.

“So at these kinds of cutting edge, high-end hospitals, we're still seeing these major problems,” Valley says. “So what does that mean for the average community hospital out there?”

The researchers say they’d like to see more studies on deep sedation in hospitals and the factors in its use.

Hospitals and health systems need to take a closer look at how many patients are being placed in deep sedation, Valley says.

“From my standpoint, I would like to see kind of an all hands-on-deck mentality to address sedation as a problem. You know, to me, sedation is probably one of the biggest problems we can readily address in the ICU,” Valley says.

It’s also a problem that can be addressed without investing a lot of money or inventing a new drug, he says.

“This is a readily addressable problem that requires an intervention,” Valley says. “It's going to require a lot of work, but this is something we should be able to do for every patient in the ICU to ensure that they are not deeply sedated.”

Armstrong-Hough also says she hopes the study will draw greater attention to the problems of putting patients in deep sedation when it’s not necessary.

“It's a problem, but that is a modifiable problem,” she says. “And what I want to see is a concerted effort to do the things that we need to do.”