Bolus-Based Fentanyl Regimen Decreases Opioid Use and Improves Adult ICU Patient Outcomes

Introduction: The ICU Liberation Bundle (A-F) provides a framework of evidence-based recommendations to improve patient care and ICU metrics. Implementation of the A-F bundle was completed at the study site but not successfully adhered to specifically for pain and agitation identification and appropriate treatment. Barriers to successful implementation include unclear orders, knowledge deficit, and incomplete documentation. Fentanyl orders were adjusted to clearly communicate that boluses must be prioritized. If more than 3 boluses were needed in 1 hour, addition or up titration of the fentanyl infusion should occur. It was hypothesized that after updates to pre-populated fentanyl orders in the EMR and multidisciplinary education, there would be improvements in ventilator days, ICU length of stay (LOS) and hospital LOS.


Methods: This quality improvement project included adult patients who were on a ventilator for at least 24 hours in a 31-bed medical-surgical ICU. Baseline nursing adherence data was collected from March 2024 to April 2024, 25 patients. Adherence data included CPOT score collection, correct intervention based on CPOT/RASS, and adherence to medication administration instructions. After changes to fentanyl instructions in the EMR and extensive nursing education, follow up adherence data was collected from April 2025 to June 2025, 23 patients. Outcomes data was then collected and compared for ventilator days, ICU LOS, and hospital LOS.


Results: Appropriate CPOT scores were obtained in 115/281 (40.9%) in 2024 compared to 322/383 (84.1%) in 2025. Correct intervention was performed based on CPOT/RASS in 43/131 (32.8%) in 2024 compared to 154/217 (71%). Order compliance in 2024 was 57/91 (62.6%) compared to 184/189 (97.4%) in 2025. Up-titrations were reduced from 3.6 to 0.9 titrations per patient, demonstrating decreased opioid use. For outcomes data for quarter 1 of 2024 compared to quarter 1 of 2025, ventilator days reduced from 4 to 2.2 days, ICU LOS reduced from 3.7 to 3.1 days, and hospital LOS reduced from 8.5 to 6.1 days.


Conclusions: Education to better utilize CPOT scores and EMR changes to clearly implement a bolus-based fentanyl regimen as part of the A-F bundle led to significant reductions in ventilator days, ICU LOS and hospital LOS.