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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. Epidemiology ICU-Acquired Delirium & Weakness. Delirium 20-50% non-MV ICU 81-83% MV ICU 50-80% S/T/B ICU

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applying the abcde bundle into clinical practice

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
University of Nebraska Medical CenterEpidemiology ICU-Acquired Delirium & Weakness
  • Delirium
    • 20-50% non-MV ICU
    • 81-83% MV ICU
    • 50-80% S/T/B ICU
  • ICU Acquired Weakness (AW)
    • 25-50% of all patients who receive MV for 4-7 day
    • 50-75% sepsis patients
outcomes associated with delirum
University of Nebraska Medical CenterOUTCOMES 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
outcomes associated with delirium
University of Nebraska Medical CenterOUTCOMES 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
outcomes associated with icu aw
University of Nebraska Medical CenterOUTCOMES 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
icu outcomes
University of Nebraska Medical CenterICU 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
who is responsible for improving outcomes
University of Nebraska Medical CenterWHO IS RESPONSIBLE FOR IMPROVING OUTCOMES?
  • Nurses
  • Respiratory Therapists
  • Physical Therapists
  • Pharmacists
  • Medical Doctors
  • Administration
slide8
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
the story what we knew
University of Nebraska Medical CenterTHE STORYWHAT WE KNEW
  • Administrative “buy-in”
  • Open ICUs
  • CCS delivery
  • Current policy
  • Research vs. practice
    • Outcomes of interest
    • IRB
    • Subject recruitment
the story what we did
University of Nebraska Medical CenterTHE STORYWHAT WE DID
  • Synthesis & presentation of ABCDE bundle
  • Interprofessional focus groups
    • Knowledge deficits
    • Communication challenges
    • Documentation
    • Current policy
    • Applicability
    • Accountability
    • Staffing ratios/patterns
the story what we did1
University of Nebraska Medical CenterTHE STORYWHAT WE DID
  • Developed TNMC policy
    • Continual staff feedback
    • Committee approval
  • Education, Education, Education
    • Visiting professor
    • Interprofessional in-services
    • 8 hour nursing in-service
    • Technology
    • On-line, interprofessional, CE credits
the story this is what we developed
University of Nebraska Medical CenterTHE 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
abc steps
University of Nebraska Medical CenterABC “STEPS”
  • Spontaneous Awakening Trial Safety Screen
    • RN Driven
  • Spontaneous Awakening Trial
    • RN Driven
  • Spontaneous Breathing Trial Safety Screen
    • RT Driven
  • Spontaneous Breathing Trial
    • RT Driven
step 1 sat safety screen rn driven
Step 1 –SAT Safety Screen-RN Driven

SAT Safety Screen Questions

  • 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?
  • All SAT Safety Screen Questions answered NO:
    • Conclude it is SAFEto 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 SAFEto 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
step 2 perform sat rn driven
Step 2-Perform SAT-RN Driven

SAT Failure Questions

  • 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:
  • 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 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

step 3 perform sbt safety screen rt driven
Step 3-Perform SBT Safety Screen-RT Driven

SBT Safety Screen Questions

  • Is patient a chronic/ventilator dependent patient?
  • Is patient SpO2<88%?
  • Is patient’s FiO2>50%?
  • Is patient’s set PEEP >7?
  • Is there documentation of myocardial ischemia in the past 24 hours?
  • Is the patient currently on vasopressor medications?
  • Is patient’s intracranial Pressures > 20?
  • Is patient receiving mechanical ventilation in an attempt to control ICP?
  • Does the patient lack inspiratory effort?
  • Any SBT Safety Screen Questions answered YES:
    • Conclude it is NOT SAFEto 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
  • All SBT Safety Screen Questions answered NO:
    • Conclude it is SAFE to perform a SBT
    • Proceed to Step 4
step 4 perform sbt rt driven

SBT Failure Questions

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

Step 4-Perform SBT-RT Driven
  • Any SBT Failure Criteria Questions answered YES:
    • Conclude the patient has FAILEDthe 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
why is delirium so confusing
University of Nebraska Medical CenterWHY IS DELIRIUM SO CONFUSING?

Acute Confusion

Sun-downing

ICU psychosis

Altered mental status

Cerebral insufficiency

Toxic or metabolic encephalopathy

Organic brain syndrome

Dementia

Acute brain dysfunction

“Just ain’t right”

delirium monitoring management
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
delirium monitoring management1

Brain Road Map

Delirium Monitoring & Management

Each day during interdisciplinary rounds, the RN will:

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

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:

Eliminate or minimize risk factors

Provide a therapeutic environment

1. Where is the patient going?

Target RASS

2. Where is the patient now?

Current RASS

Current CAM-ICU

3. How did they get there?

Drugs

nonpharmacologic approaches to preventing treating delirium
University of Nebraska Medical CenterNONPHARMACOLOGIC 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

N – Neurologic

    • Patient response to verbal stimulation (i.e. RASS > -3)
    • Activity not started in comatose patients (RASS -4 or -5)
  • R – Respiratory
    • FIO2<0.6
    • PEEP<10 cm H2O
  • 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
Early Mobility-Safety Screen-RN Driven
  • If Early Mobility Safety Screen criteria are MET :
    • -Conclude it is SAFE to begin early mobility protocol
  • If Early Mobility Safety Screen criteria are NOTMET :
    • Conclude it is NOT SAFEto 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
Early Mobility Progression

Walking

A

Short Distance

Standing at bedsideand

sitting in chair

Sitting on edge of bed

abcde summary points
University of Nebraska Medical CenterABCDE 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.
abcde summary points1
University of Nebraska Medical CenterABCDE 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.
slide30

University of Nebraska Medical Center

University of Nebraska Medical Center

THANK YOU !!!!!!