Introduction

1. Frequency of use of analgesics and sedatives during day vs. night shift in Pediatric Ward and Pediatric Intensive Care Unit. Santiago Encalada, M.D. Deeni de la Rosa, M.D. Kevin Schooler, M.D. PhD. Driscoll Children’s Hospital. Introduction Results The use of analgesics, sedatives, and paralytic agents are an important tool to help decrease pain and anxiety while improving the quality of life and care of the patient. Using medications on an “as needed” or PRN (from Latin: Pro Re Nata) basis potentially decreases the amount of medication to be administered reducing both side effects and costs while improving patient comfort. However, since pain and discomfort are subjective, misuse or overuse of PRN medications can occur and the beneficial effects may be lost. To date there are no publications that address this subject. We analyzed a total of 18305 doses across 183 days. Floors/Ward. There are more PRN medications used during the day shift except for diphenhydramine where there is no difference (P 0.42) of usage between day and night shifts. Morphine showed the biggest usage difference between shifts (an average of 2.6 more doses are administered during the day). PICU For Acetaminophen, Fentanyl, Ibuprofen and Vecuronium, there were no statistical difference between the number of PRN doses given during day or night shifts. However, there were more doses of Diphenhydramine, Midazolam and Morphine given at night. Interestingly, there is a significantly higher usage of morphine at night while there is no statistical difference in Fentanyl dosing. Abstract Analgesics, sedatives and paralytics are important tools for decreasing pain and anxiety in patients. They are absolutely essential for providing quality patient care. PRN medications (From Latin: Pro Re Nata, when necessary) can decrease the amount of medication administered to a given patient and may, therefore, reduce both the side effects and costs of patient care while improving patient comfort. However, if these medications are overused, or misused, the potential benefits will be lost. To date there is a paucity of data that addresses this subject in the Pediatric population. This study examines the different usage of PRN medications in pediatric wards and in the Pediatric intensive care unit (PICU). We hypothesized that the usage of PRN analgesics, sedatives and muscle paralyzing agents would be significantly higher during the night shift. The total number of doses analgesics, sedatives and paralytics given over a 6 month period was retrieved from the electronic medical record. The medications used on the wards included: Acetaminophen, Acetaminophen with codeine, Ibuprofen, Ketorolac, Diphenhydramine and Morphine. In the PICU, the medications analyzed were: Acetaminophen, Ibuprofen, Diphenhydramine, Morphine, Fentanyl, Midazolam and Vecuronium. We did not include medications given via continuous drips or by PCA pumps. Doses given during the day shift vs. night shift were determined on a day by day basis and the analyzed for statistical significance using a Paired T test. In the wards, all medications except for Diphenhydramine were given more during the day shift compared to the night shift. For Diphenhydramine, there was no difference between day and night shifts. In the PICU, Morphine, Midazolam and Diphenhydramine were given more during the night shift compared to the day shift. Figure 1: Average Dose Difference Between Day and Night Shift in Floors Hypothesis We hypothesize that the use of PRN analgesics, sedatives and muscle paralyzing agents will be significantly higher during the night shift, independent of the overall medical status of the patients. Description of study • Retrospective cohort, single center study • Data was extracted from electronic medical records (EPIC), to include the following information: • From July 1 2012 to Dec 31 2012. • From Floors/Wards: Administered PRN doses of: Acetaminophen, Acetaminophen with Codeine, Diphenhydramine, Ibuprofen, Ketorolac, Morphine • From PICU: Administered PRN doses of: Acetaminophen, Diphenhydramine, Ibuprofen, Morphine, Fentanyl, Midazolam, Vecuronium. • Exclusion criteria: patients who receive no PRN sedatives, analgesics or paralytic agents or patients that receive medication via a PCA (Patient Controlled Analgesia) pump or via continuous infusion (drips). • The data was de-identified as required by HIPPA regulations and Driscoll Children’s Hospital policy. • We tabulated the data from day shift vs. night shift in a day by day basis (in order to be able to pair patient number and eliminate discrepancies due to variations in census) • The data was then analyzed using Paired T test (based on the information from each day) with an statistical analysis software (R Package) Figure 2: Average Dose Difference Between Day and Night Shift in PICU Table 3: Demographics. Conclusions The design of this study does not allow us to determination why there is a difference between PRN medications during day and night shifts. However, we hypothesize that the increase use of PRN medications during the day on the pediatric wards could be related to the increase need for patient activity during the day (ambulation, procedures, wound care, feeding, imaging and labs, etc.). In addition, the clinical staff is frequently busier during the day as compared to the night. There are also more visitors and family members in the patients rooms during the day. These visitors could influence PRN usage on behalf of the patient without understanding the patient’s actual level of discomfort. In comparison to the PICU, patients on the pediatric wards are more verbal (not intubated, not sedated) and would therefore be more likely to request medications while awake or simply express their symptoms/discomfort. By definition, the floor has less monitoring and fewer objective scales to assess pain and discomfort compared to the PICU. In the PICU, only Morphine, Midazolam and Diphenhydramine usage showed a significant difference between shifts. As stated above, this study is not designed to determine the cause of this finding. It may be that the result demonstrates an attempt to preserve the patient’s sleep awake cycle. This is a novel study and addresses a gap in knowledge regarding pediatric medication dosing. Having more insight into the etiological factors of our results will elucidate important details in dosing behaviors and improve quality of care in the Pediatric population. Table 1: Average Dose Difference Between Day and Night Shift in the Floors/Ward References Table 2: Average Dose Difference Between Day and Night Shift in the Floors/Ward Available upon request 2013 Texas Pediatric Society Electronic Poster Contest