Critical care primary services are associated with reduced midazolam use in the intensive care unit

Analgesia and sedation are commonly prescribed therapies within the intensive care unit (ICU) for patients receiving mechanical ventilation. Current guidelines recommend utilizing an analgesia-first approach to initially reach appropriate pain control, while potentially achieving sedation goals concurrently. Our system employs a guideline-based ICU sedation order-set that features an electronic medical record (EMR) integrated ICU checklist that combines analgesia and sedation.

To identify systems-based factors that are associated with the use of continuous midazolam infusion administration in mechanically ventilated patients.

We extracted EMR data from patients who received mechanical ventilation between January 1, 2021, and December 31, 2023. Subjects included were 18 years or older who received mechanical ventilation. "R" version 4.3.2 was used for data processing and statistical analysis. We performed a multivariable regression analysis to predict the administration of a continuous midazolam infusion with modified Sequential Organ Failure Assessment score, Charlson comorbidity index, and critical care medicine (CCM) primary service.

Of 3805 patients that underwent mechanical ventilation, 62% were male, with a mean age of 66.9 years. 3429 patients were treated by a provider team with a CCM attending, and 376 patients were managed by a non-CCM primary team with CCM consultative services. A midazolam infusion was used in 187 of 3429 (5%) patients with CCM as primary and in 166 of 376 (56%) patients with non-CCM primary (χ ² 598.23, P < 0.001). Of the patients who received continuous midazolam, 117 (21%) died vs 236 (7%) survived hospitalization. Continuous midazolam was associated with more days with coma and more days with delirium (P < 0.0001).

Continuous midazolam infusion was more likely in patients admitted to the ICU under an open unit with a non-CCM physician with an intensivist consult available, despite guided order-sets and checklists integrated into the EMR.