Semester

Summer

Date of Graduation

2026

Document Type

Problem/Project Report

Degree Type

DNP

College

School of Nursing

Committee Member

Mike Frame

Committee Member

Amanda Foster

Abstract

Introduction: Awake paralysis (AWP) occurs when long-acting neuromuscular blockers outlast short-acting sedatives during intubation, leaving patients chemically paralyzed but conscious. This highlights the critical need for timely post-intubation sedation.

Background: A 2024 review in the Neurological Critical Care Unit (NCCU) revealed that 72% of patients who received rocuronium were not given a post-intubation sedative. The difference in duration of action of paralyzing agents versus sedatives can result in patients being conscious while paralyzed, potentially resulting in hemodynamic instability and psychological harm.

Purpose: The quality improvement initiative aimed to reduce the number of patients receiving neuromuscular blocking agents without post-intubation sedation.

Methods/Interventions: A three-month QI initiative combined staff education and implementation of an intubation algorithm. Education included presentations, flyers, and a badge buddy reference with the algorithm. The algorithm outlined medication choices, drug durations, and prompted a proper sedative choice.

Results: A final sample of 48 patients was studied amongst the pre- and post-intervention groups. The mean time to sedation was 17.91 minutes in the pre-intervention group and 8.19 minutes in the post-intervention group.  The incidence of patients receiving a sedative after paralytic was 6 of 22 patients (27.27%) in the pre-intervention and improved to 21 of 26 patients (80.77%) in the post-intervention group. An independent samples t-test, assuming unequal variances, demonstrated a statistically significant reduction in sedation time in the post-intervention group (p = 0.049). A chi-square test of independence was performed to examine the association between the intervention and sedation adequacy, and the result was statistically significant (p < .001). The project had no impact on the utilization of succinylcholine, as it was not used for any intubation during the post-intervention period. The Acceptability of Intervention Measure (AIM) survey was completed by 39 staff members from NCCU. The average total score was 19.6 out of 20, indicating strong endorsement of the algorithm. Excellent reliability of the survey was determined, with a Cronbach’s alpha of 0.978.

Conclusions: A QI project that included targeted education and the implementation of an intubation algorithm effectively reduced the number of patients paralyzed without sedation. This project led to more consistent and timely administration of sedatives following neuromuscular blockade. This initiative may serve as a scalable model for other like units across the health system.

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