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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
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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
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
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OUR TEAM
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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
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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
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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
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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 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
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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
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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
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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 !!!!!!