Applying the “ABCDE” Bundle into Clinical Practice

Michele C. Balas PhD, APRN-NP, CCRN

Assistant Professor

University of Nebraska Medical Center

College of Nursing

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

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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

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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

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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

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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

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WHO IS RESPONSIBLE FOR IMPROVING OUTCOMES?

• Nurses

• Respiratory Therapists

• Physical Therapists

• Pharmacists

• Medical Doctors

• Administration

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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

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OUR TEAM

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THE STORYWHAT WE KNEW

•Administrative “buy-in”

•Open ICUs

•CCS delivery

•Current policy

•Research vs. practice

1. Outcomes of interest

2. IRB

3. Subject recruitment

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THE STORYWHAT WE DID

• Synthesis & presentation of ABCDE bundle

• Interprofessional focus groups

• Knowledge deficits

• Communication challenges

• Documentation

• Current policy

• Applicability

• Accountability

• Staffing ratios/patterns

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THE STORYWHAT 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

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THE STORYTHIS 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

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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

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Step 1 –SAT Safety Screen-RN Driven

SAT Safety Screen Questions1. 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?

•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

•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

SAT Failure Questions1.RASS score > 2 for >5 minutes 2.Sa02 < 88 % for> 5 minutes3.Respirations >35 BPM for >5 minutes4.New Acute Cardiac Arrhythmia5.ICP >206.2 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

•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:

• Any SAT Failure Criteria Questions answered YES:

Step 2-Perform SAT-RN Driven

- 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

- Conclude the patient has PASSED the SAT - RN will ask the RT to immediately perform a SBT safety screen Step 3

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?

9.Does the patient lack inspiratory effort?•All SBT Safety Screen Questions answered NO:

•Conclude it is SAFE to perform a SBT•Proceed to Step 4

•Any SBT Safety Screen Questions answered YES:

•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

Step 3-Perform SBT Safety Screen-RT Driven

Step 4-Perform SBT-RT Driven

• Any SBT Failure Criteria Questions answered YES:

• Conclude the patient has FAILED the SBT

• Restart mechanical ventilation at previous settings

• Repeat step 3 in 24 hours• Ask RN to restart sedatives at ½ the

previous dose only if needed• Determine possible causes of the SBT

failure during interdisciplinary rounds

•If the patient tolerates the SBT for 30-120 minutes without failure criteria

• Conclude the patient has PASSED the SBT

• Inform the physician that the patient has PASSED the SBT

• Physician should consider extubation

SBT Failure Questions1.Respirations >35/minute for > 5 minutes 2.Respiratory rate <83.Sp02 <88% 4.Mental status changes5.Acute cardiac arrhythmia6.ICP >207.2 or more of the following symptoms of respiratory distress: Accessory Muscle use, Abdominal Paradox, Diaphoresis, Dyspnea, Mental status changes, Acute cardiac arrhythmia

WHY IS DELIRIUM SO CONFUSING?

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Acute Confusion Sun-downing

ICU psychosis

Toxic or metabolic encephalopathy

Dementia

Cerebral insufficiency

Acute brain dysfunction

Altered mental status

Organic brain syndrome

“Just ain’t right”

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

Each day during interdisciplinary rounds, the RN will:

1.State the “TARGET” RASS score 2.State the patient’s ACTUAL RASS score3.State the CAM-ICU status4.State the sedative/analgesic medications the patient is currently receiving

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.Eliminate or minimize risk factors 2.Provide a therapeutic environment

1. Where is the patient going?Target RASS

2. Where is the patient now?Current RASSCurrent CAM-ICU

3. How did they get there?Drugs

Brain Road Map

NONPHARMACOLOGIC APPROACHES TO PREVENTING & TREATING DELIRIUM

•USE MEDICATIONS ONLY IF ABSOLUTELY NECESSARY!!!!!!!!!!!!!!!!

•Give “PEACE” a chance• Physiologic• Environmental• ADLs/Sleep• Communication• Education

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Early Mobility-Safety Screen-RN Driven1. 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 are MET :

• -Conclude it is SAFE to begin early mobility protocol

• 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

Early Mobility Progression

WalkingA

Short Distance

Standing at bedsideand

sitting in chair

Sitting on edge of bed

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.

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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.

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OUR GOAL!

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THANK YOU !!!!!!