Applying the “ABCDE” Bundle into Clinical Practice Michele C. Balas Ph. D, APRN-NP, CCRN Assistant Professor University of Nebraska Medical Center College of Nursing
University of Nebraska Medical Center Epidemiology ICU-Acquired Delirium & Weakness • Delirium 1. 20 -50% non-MV ICU 2. 81 -83% MV ICU 3. 50 -80% S/T/B ICU • ICU Acquired Weakness (AW) 1. 25 -50% of all patients who receive MV for 4 -7 day 2. 50 -75% sepsis patients
University of Nebraska Medical Center OUTCOMES ASSOCIATED WITH DELIRUM • 10 -fold risk of in-hospital death • • Each additional day of delirium risk of dying 10% Increased risk of: • Prolonged ICU & hospital LOS • Nosocomial complications • Greater use of continuous sedation & physical restraints • Increased self-removal of catheters & ETTs
University of Nebraska Medical Center OUTCOMES ASSOCIATED WITH DELIRIUM • Poor functional recovery & loss of independence • Risk of death up to 2 years following discharge • Post-acute care nursing-home placement • Long-term cognitive impairment • Total 1 -year health-care costs of delirium $38 billion to $152 billion nationally • Hip fracture-$7, falls $19 billion, diabetes $91 billion, CV disease $257 billion
University of Nebraska Medical Center OUTCOMES ASSOCIATED WITH ICU-AW • 80 -95% of patients with ICU-AW have neuromuscular abnormalities 2 -5 YEARS after discharge • 70% of MV patients have difficulty with ADLs 1 year after discharge
University of Nebraska Medical Center ICU OUTCOMES • 30 -80% of ALL patients have cognitive impairment after ICU discharge • Some improve within 1 year, but many others NEVER return to baseline level • 10 -50% of ICU survivors experience PTSD, depression, anxiety, & sleep disorders • • Problems may persist years after discharge 50% of ALL ICU survivors require caregiver assistance 1 year after discharge
University of Nebraska Medical Center WHO IS RESPONSIBLE FOR IMPROVING OUTCOMES? • Nurses • Respiratory Therapists • Physical Therapists • Pharmacists • Medical Doctors • Administration
University of Nebraska Medical Center Study Aims • Implement the ABCDE bundle in a medical center that does not currently perform routine ICU delirium screenings & identify facilitators & barriers to program adoption • Test the impact of the ABCDE program on patient, nursing quality, & system outcomes • Assess the extent to which ABCDE implementation is effective, sustainable, & conducive to dissemination into other settings
University of Nebraska Medical Center OUR TEAM
University of Nebraska Medical Center THE STORY WHAT WE KNEW • Administrative “buy-in” • Open ICUs • CCS delivery • Current policy • Research vs. practice 1. Outcomes of interest 2. IRB 3. Subject recruitment
University of Nebraska Medical Center THE STORY WHAT WE DID • Synthesis & presentation of ABCDE bundle • Interprofessional focus groups • Knowledge deficits • Communication challenges • Documentation • Current policy • Applicability • Accountability • Staffing ratios/patterns
University of Nebraska Medical Center THE STORY WHAT WE DID • Developed TNMC policy 1. Continual staff feedback 2. Committee approval • Education, Education 1. Visiting professor 2. Interprofessional in-services 3. 8 hour nursing in-service 4. Technology • On-line, interprofessional, CE credits
University of Nebraska Medical Center THE STORY THIS IS WHAT “WE” DEVELOPED • TNMC ABCDE BUNDLE • Purpose • To who do is it apply? • Opt “out” vs. opt “in” policy • 3 distinct, yet highly interconnected components • Awakening & Breathing trial Coordination • Delirium monitoring & management • Early mobility
University of Nebraska Medical Center ABC “STEPS” 1. Spontaneous Awakening Trial Safety Screen • RN Driven 2. Spontaneous Awakening Trial • RN Driven 3. Spontaneous Breathing Trial Safety Screen • RT Driven 4. Spontaneous Breathing Trial • RT Driven
University of Nebraska Medical Center
Step 1 –SAT Safety Screen-RN Driven SAT Safety Screen Questions 1. 2. 3. 4. 5. 6. 7. 8. Is patient receiving a sedative infusion for active seizures? Is patient receiving a sedative infusion for ETOH withdrawal? Is patient receiving a paralytic agent? Is patient’s RASS score >2? Is there documentation of myocardial ischemia in the past 24 hours? Is patient’s ICP > 20? Is patient receiving sedative medications in an attempt to control intracranial pressures? Is patient currently receiving ECMO? • Any SAT Safety Screen Questions answered YES: – Conclude it is NOT SAFE to shut off patient’s continuous analgesic or sedative infusions – Continue the patient’s regimen & reassess in 24 hours – Discuss the patient’s condition during interdisciplinary rounds • All SAT Safety Screen Questions answered NO: – Conclude it is SAFE to perform a SAT – Turn off all continuous sedative infusions – Hold all sedative boluses – PRN analgesics allowed –Continuous analgesic infusions maintained only if needed for active pain – Proceed to Step 2
Step 2 -Perform SAT-RN Driven SAT Failure Questions 1. RASS score > 2 for >5 minutes 2. Sa 02 < 88 % for> 5 minutes 3. Respirations >35 BPM for >5 minutes 4. New Acute Cardiac Arrhythmia 5. ICP >20 6. 2 or more of the following symptoms of respiratory distress: • HR increase 20 or more BPM, HR <55 BPM, Use of accessory muscles, Abdominal paradox, Diaphoresis, Dyspnea • Any SAT Failure Criteria Questions answered YES: - Conclude the patient has FAILED the SAT - Restart the patient’s sedation at ½ the previous dose & then titrate to sedation target - Interdisciplinary team will determine possible causes of the SAT failure during rounds - Repeat Step 1 in 24 hours • If patient able to open his/her eyes to verbal stimulation without failure criteria (regardless of trial length) OR does not display any of the failure criteria after 4 hours of shutting of sedation: - Conclude the patient has PASSED the SAT - RN will ask the RT to immediately perform a SBT safety screen Step 3
Step 3 -Perform SBT Safety Screen-RT Driven SBT Safety Screen Questions 1. Is patient a chronic/ventilator dependent patient? 2. Is patient Sp. O 2 <88%? 3. Is patient’s Fi. O 2 >50%? 4. Is patient’s set PEEP >7? 5. Is there documentation of myocardial ischemia in the past 24 hours? 6. Is the patient currently on vasopressor medications? 7. Is patient’s intracranial Pressures > 20? 8. Is patient receiving mechanical ventilation in an attempt to control ICP? • Any SBT Safety Screen Questions • All 9. Does the patient lack inspiratory effort? SBT Safety Screen Questions answered YES: answered NO: • Conclude it is NOT SAFE to perform a SBT • Continue mechanical ventilation & repeat step 3 in 24 hours • RT will ask the RN to restart sedatives at ½ the previous dose only if needed • Discuss the patient’s condition during interdisciplinary rounds • Conclude it is SAFE to perform a SBT • Proceed to Step 4
Step 4 -Perform SBT-RT Driven SBT Failure Questions 1. 2. 3. 4. 5. 6. 7. Respirations >35/minute for > 5 minutes Respiratory rate <8 Sp 02 <88% Mental status changes Acute cardiac arrhythmia ICP >20 2 or more of the following symptoms of respiratory distress: Accessory Muscle use, Abdominal Paradox, Diaphoresis, Dyspnea, Mental status changes, Acute cardiac arrhythmia • Any SBT Failure Criteria Questions answered • If the patient tolerates the SBT for 30 -120 YES: minutes without failure criteria • Conclude the patient has FAILED the • Conclude the patient has PASSED SBT the SBT • Restart mechanical ventilation at previous • Inform the physician that the settings patient has PASSED the SBT • Repeat step 3 in 24 hours • Physician should consider • Ask RN to restart sedatives at ½ the extubation previous dose only if needed • Determine possible causes of the SBT failure during interdisciplinary rounds
University of Nebraska Medical Center WHY IS DELIRIUM SO CONFUSING? Acute Confusion ICU psychosis Toxic or metabolic encephalopathy Dementia “Just ain’t right” Sun-downing Altered mental status Cerebral insufficiency Organic brain syndrome Acute brain dysfunction
Delirium Monitoring & Management • Routine Sedation & Delirium Assessment Using Standardized, Validated Assessment Tools • RN administers & records RASS results q 2 h • Team sets “target” RASS score for the patient to be maintained at for the following 24 hours • RN administers & records results of the CAM-ICU q 8 h & whenever a patient experiences a change in mental status
What is the CAM-ICU?
Delirium Monitoring & Management Brain Road Map Each day during interdisciplinary rounds, the RN will: 1. 2. 3. 4. State the “TARGET” RASS score State the patient’s ACTUAL RASS score State the CAM-ICU status State the sedative/analgesic medications the patient is currently receiving 1. Where is the patient going? Target RASS Each day during interdisciplinary rounds, the team will use the acronym “THINK” if a patient is CAM positive (delirious) The interdisciplinary team will employ the following non-pharmacologic interventions when treating a delirious patient: 1. 2. Where is the patient now? Current RASS Current CAM-ICU Eliminate or minimize risk factors Provide a therapeutic environment 3. How did they get there? Drugs
University of Nebraska Medical Center NONPHARMACOLOGIC APPROACHES TO PREVENTING & TREATING DELIRIUM • USE MEDICATIONS ONLY IF ABSOLUTELY NECESSARY!!!!!!!! • Give “PEACE” a chance • • • Physiologic Environmental ADLs/Sleep Communication Education
Early Mobility-Safety Screen-RN Driven 1. N – Neurologic • • Patient response to verbal stimulation (i. e. RASS > -3) Activity not started in comatose patients (RASS -4 or -5) 2. R – Respiratory • • FIO 2<0. 6 PEEP<10 cm H 2 O 3. C – Circulatory • • No increase dose of any vasopressor infusion for at least 2 hours No evidence of active myocardial ischemia No arrthymia requiring the administration of a new antiarrythmic agent Not receiving therapies that restrict mobility • ECMO, Open-abdomen, ICP monitoring/drainage, Femoral arterial line • If Early Mobility Safety Screen criteria are NOT MET : • • • Conclude it is NOT SAFE to begin early mobility protocol Continue patients regimen & reassess in 24 hours Discuss the patient’s condition during interdisciplinary rounds • Any other justification for not implementing the protocol must be written specifically by a licensed prescriber • If Early Mobility Safety Screen criteria are MET : • -Conclude it is SAFE to begin early mobility protocol
Early Mobility Progression Walking A Short Distance Standing at bedside and sitting in chair Sitting on edge of bed
University of Nebraska Medical Center ABCDE SUMMARY POINTS • Cognitive & functional decline in the ICU must change from being viewed as “part of the inevitable consequences of critical illness” to a modifiable condition. • Improvement requires evolution in critical care team roles. • Teams must shift from multidisciplinary to interdisciplinary care.
University of Nebraska Medical Center ABCDE SUMMARY POINTS • ABCDE should become the default practice. • Patients will wake up, breath, & exercise if we allow them. • Checklists and daily goals should be used; not elegant, but effective. • Incorporate process & outcomes monitoring.
University of Nebraska Medical Center OUR GOAL!
University of Nebraska Medical Center University of Nebraska Medical THANK YOU !!!!!! Center
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