Download Document

Survey
yes no Was this document useful for you?
   Thank you for your participation!

* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project

Document related concepts
no text concepts found
Transcript
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.
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.
2.
3.
4.
5.
6.
RASS score > 2 for >5 minutes
Sa02 < 88 % for> 5 minutes
Respirations >35 BPM for >5 minutes
New Acute Cardiac Arrhythmia
ICP >20
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 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?
•Any9.SBT
Safety
•All SBT Safety Screen Questions
Does
theScreen
patientQuestions
lack inspiratory effort?
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
Sp02 <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 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.
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.
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
•
•
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 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
THANK YOU !!!!!!