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Applying the “ABCDE” Bundle into Clinical Practice Michele C. Balas PhD, 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, 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. Is patient receiving a sedative infusion for active seizures? 2. Is patient receiving a sedative infusion for ETOH withdrawal? 3. Is patient receiving a paralytic agent? 4. Is patient’s RASS score >2? 5. Is there documentation of myocardial ischemia in the past 24 hours? 6. Is patient’s ICP > 20? 7. Is patient receiving sedative medications in an attempt to control intracranial pressures? 8. Is patient currently receiving ECMO? •Any SAT Safety Screen Questions •All SAT Safety Screen Questions answered YES: answered NO: – Conclude it is NOT SAFE to shut off – Conclude it is SAFE to perform a SAT patient’s continuous analgesic or sedative – Turn off all continuous sedative infusions infusions – Hold all sedative boluses – Continue the patient’s regimen & – PRN analgesics allowed reassess in 24 hours –Continuous analgesic infusions maintained – Discuss the patient’s condition during only if needed for active pain interdisciplinary rounds – Proceed to Step 2 Step 2-Perform SAT-RN Driven SAT Failure Questions 1. RASS score > 2 for >5 minutes 2. Sa02 < 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 •If patient able to open his/her eyes to answered YES: verbal stimulation without failure criteria (regardless of trial length) OR - Conclude the patient has FAILED the SAT does not display any of the failure - Restart the patient’s sedation at ½ the previous dose & then titrate to sedation target criteria after 4 hours of shutting of - Interdisciplinary team will determine possible sedation: causes of the SAT failure during rounds - Conclude the patient has PASSED the - Repeat Step 1 in 24 hours 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 SpO2 <88%? 3. Is patient’s FiO2 >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 SBT Safety Screen Questions 9. Does the patient lack inspiratory effort? answered YES: answered NO: •Conclude it is NOT SAFE to perform a SBT •Conclude it is SAFE to perform a SBT •Continue mechanical ventilation & repeat •Proceed to Step 4 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 Step 4-Perform SBT-RT Driven SBT Failure Questions 1. Respirations >35/minute for > 5 minutes 2. Respiratory rate <8 3. Sp02 <88% 4. Mental status changes 5. Acute cardiac arrhythmia 6. ICP >20 7. 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 Sun-downing ICU psychosis Altered mental status Toxic or Cerebral metabolic insufficiency encephalopathy Organic brain syndrome Dementia “Just ain’t right” Acute brain dysfunction Delirium Monitoring & Management • Routine Sedation & Delirium Assessment Using Standardized, Validated Assessment Tools • RN administers & records RASS results q2h • 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 q8h & 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. State the “TARGET” RASS score 2. State the patient’s ACTUAL RASS score 3. State the CAM-ICU status 4. 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 2. Where is the patient now? following non-pharmacologic interventions Current RASS when treating a delirious patient: Current CAM-ICU 1. Eliminate or minimize risk factors 2. 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 • FIO2<0.6 • PEEP<10 cm H2O 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 • If Early Mobility Safety Screen criteria are NOT MET : are MET : • Conclude it is NOT SAFE to begin early • -Conclude it is SAFE to begin early mobility protocol 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 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 THANK YOU !!!!!!