1. Applying the “ABCDE” Bundle into Clinical Practice
Michele C. Balas PhD, APRN-NP, CCRN
Assistant Professor
University of Nebraska Medical Center
College of Nursing

2. Epidemiology ICU-Acquired Delirium & Weakness
University of Nebraska Medical Center
Epidemiology 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

3. OUTCOMES ASSOCIATED WITH DELIRUM
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
There remains a common misconception that delirium is a relatively “benign” syndrome. That delirium is something most older adults experience when they are sick, that it really doesn’t hurt them , and that it will just go away before they go back home.
We now know that this is absolutely NOT the case. Delirium is ACTUALLY one of the most common, costly, and dangerous conditions someone can develop.
For example, patients who develop delirium during their hospital stay are now known to experience a 10 fold increased risk of in-hospital death. They also expereince a 3-5 fold increase risk of nosocomial complications. These complications include self-extubation, self removal of tubes and catheters, falls. The agitation and lethargy associated with delirium is also believed to lead to aspiration, pressure ulcers, pulmonary emboli, and decreased oral intake. This 3-5 fold increased risk also extends to ICU, hospital, and post-hospital LOS. Patients with delirium are more likely to require some form of post-acute care placement whether it be in nursing homes, rehabilitation centers, or long-term care hospitals.
We now know that delirium also doesn’t always “go away” right at hospital discharge. Delirium has been found to be an independent predictor of…..
More importantly, we now know some patients never recover from an episode of delirium and develop LT cognitive impairment/dementia.

4. OUTCOMES ASSOCIATED WITH DELIRIUM
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
Hip fracture-$7, falls $19 billion, diabetes $91 billion, CV disease $257 billion

5. OUTCOMES ASSOCIATED WITH ICU-AW
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

6. 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

7. WHO IS RESPONSIBLE FOR IMPROVING OUTCOMES?
University of Nebraska Medical Center
WHO IS RESPONSIBLE FOR IMPROVING OUTCOMES?
Nurses
Respiratory Therapists
Physical Therapists
Pharmacists
Medical Doctors
Administration

8. 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
RWJF’s Interdisciplinary Nursing Quality Research Initiative (INQRI) was created to generate, disseminate and translate knowledge related to nursing’s contribution to improving the quality of patient care.
These teams will undertake and study efforts to implement and spread evidence-based interventions in which nurses play a central, essential role and that have been shown to improve the quality of patient care. Teams that propose to translate (implement or disseminate) knowledge about an intervention for which rigorous evidence already exists will be given highest priority.
Patient (ventilator free days, delirium/coma free days, time out of bed, hospital discharge disposition, new tracheostomy rates, and ICU and hospital mortality),
Nursing quality (physical restraint use, falls, pressure ulcers, self-extubation/re-intubation, device removal rates)
System outcomes (ICU and hospital LOS, total sedative/antipsychotic medication dosing and cost, ventilator associated pneumonia rates).

9. University of Nebraska Medical Center
OUR TEAM

10. THE STORY WHAT WE KNEW Administrative “buy-in” Open ICUs CCS delivery
University of Nebraska Medical Center
THE STORY WHAT WE KNEW
Administrative “buy-in”
Open ICUs
CCS delivery
Current policy
Research vs. practice
Outcomes of interest
IRB
Subject recruitment
Ethical access
Consent

11. THE STORY WHAT WE DID Synthesis & presentation of ABCDE bundle
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
Delirium, sedation (don’t want patients to remember), patients need to sleep sleep, pain, which patients, no need for formal checklists providers know what to do,
Communictaion-Lack of interdisciplinary rounds, difference with specialists, doctor road block to treating pain, challenges to extubation resident wont decide, don’t call private practice docs atl; Trauma-You are afraid of them, not open to recommendations, gor around them to get what you want, thikn they know everything, protocosls all but for trauma patients, MDs change paramethers and take a long time to extubate, Practice form 70-80’s,. All different, change when new person comes on.pronight, put patient back on vent until they round
Documentation-nor formal screening for safety, don’t do checklist or it wont get done, daily goal sheets RNS did initially, but no one looks at them, not one cares, why should we do, pointless; if not part of the medical record wont get done; static RASS
Current policy-Need order to extubate, weaning parameters, doctors; safety screen would be valuable, 12 inch policy book Tough to remember all the policies
Applicability—don’t shut off sedation ofn ECHMO, Neuros surgey
Accountability-MDs wont follow, RNs wont change, RT ready to change, No body holds us accountable now, so why should we
Staffing-Only do for 3-4 minutes because don’t have time, need to run to next unit, not available If something goes wrong, float between floors, have to do transfers and cover ER; RN-challenge of doing with 2 patients, leads help

12. THE STORY WHAT WE DID Developed TNMC policy
University of Nebraska Medical Center
THE STORY WHAT 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

13. THE STORY THIS IS WHAT “WE” DEVELOPED
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
To reduce the frequency of ICU-acquired delirium & weakness

14. ABC “STEPS” Spontaneous Awakening Trial Safety Screen
University of Nebraska Medical Center
ABC “STEPS”
Spontaneous Awakening Trial Safety Screen
RN Driven
Spontaneous Awakening Trial
Spontaneous Breathing Trial Safety Screen
RT Driven
Spontaneous Breathing Trial

15. University of Nebraska Medical Center

16. 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?
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 1 in the ABCs is the SAT safety screen. In this step the RN will determine if it is SAFE to interrupt sedation by answering a set of questions (above)
If any of the above questions are answered YES, the RN will conclude it is NOT SAFE to shut off patient’s continuous analgesic or sedative infusions. The RN will continue the patient’s regimen & reassess in 24 hours. The interdisciplinary team will discuss the patient’s condition during rounds.
If all of the above questions are answered NO, the RN will conclude it is SAFE to perform a SAT . The RN will turn off all continuous sedative & narcotic infusions & hold all sedative boluses (prn analgesics allowed Proceed to step 2). We should always treat pain as it too could precipitate delirium.

17. 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:
In step 2, the RN will perform a SAT and determine if the patient tolderated sedation interruption. The RN will determine if the patient tolerated interruption of sedation by assessing if the patient demonstrates any of the following SAT failure criteria (above)
If the patient displays any of the SAT failure criteria, the RN will conclude the patient has failed the SAT. If the patient fails, the RN will restart the patient’s sedation BUT only at ½ the previous dose, then titrate to sedation target. The RN will repeat Step 1 in 24 hours. It is extremely important the interdisciplinary team will determine possible causes of the SAT failure during rounds.
If the patient is 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, the RN will conclude the patient has passed the SAT . If the patient passes the SAT the RN will ask the RT to immediately perform a spontaneous breathing trial safety screen (or step 3 of the ABC).
- 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

18. 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?
The next step is mainly driven by the RT. In Step 3 the RT will determine if is safe to perform a SBT by responding to the following questions (above)
If the RT determines that any of the above questions are answered YES, the RT will conclude it is NOT SAFE to perform a SBT. The RT will continue mechanical ventilation & repeat step 3 in 24 hours. The RT will ask the RN to restart sedatives at ½ the previous dose only if needed. The interdisciplinary team will discuss the patient’s condition during rounds.
If all of the above questions are answered NO, the RT will 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
All SBT Safety Screen Questions answered NO:
Conclude it is SAFE to perform a SBT
Proceed to Step 4

19. 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
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 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
If the patient passes the SBT Safety Screen, the RT will perform a SBT. The definition of SBT often varies. Examples include using(e.g., CPAP pressure support-5, CPAP PS 5 PEEP 5, T-piece etc., each institution can decide what works best for their patient population.
The RT will determine if the patient tolerated the SBT by assessing if the patient demonstrates any of the following SBT failure criteria (above)
If the patient displays any of the above symptoms, the RT will conclude the patient has failed the SBT. The RT will restart mechanical ventilation at previous settings. The RT will repeat step 3 in 24 hours & ask the RN to restart sedatives at ½ the previous dose only if needed. The interdisciplinary team will determine possible causes of the SBT failure during rounds.
If the patient tolerates the SBT for 30->120 minutes without failure criteria, the RT will inform the physician that the patient has passed the SBT. At this time, the physician should consider extubation. ACCP guidelines suggest SBT go no longer than 120 minutes.

20. WHY IS DELIRIUM SO CONFUSING?
University of Nebraska Medical Center
WHY IS DELIRIUM SO CONFUSING?
Acute Confusion
Sun-downing
ICU psychosis
Altered mental status
Cerebral insufficiency
Toxic or metabolic encephalopathy
Organic brain syndrome
One reason is the various terms used to describe the syndrome. First used as a medical term in the 1st century AD to describe mental disorders occurring during fever or head trauma.
Remains unrecognized by healthcare providers. RNs recognize and document <50% of cases MDs recognize and document only 20%
Need baseline cognitive status from caregivers particularly challenging during emergency situations.
Traditional belief that it is normal for older adults to become confused during hospital stay
Lack of knowledge regarding tools used to effectively diagnose delirium
Erroneous belief that delirium assessment is time consuming
Dangerous misconception that delirium will just “go away” and does not affect long term well being
Hypoactive delirium, the most common form, often confused with depression secondary to slowed thinking, memory impairment, and decreased concentration. For example 42% of patients referred for psych evaluation for depression were actually delirious
Different subtypes of delirium
Dementia
“Just ain’t right”
Acute brain dysfunction

21. 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
The next component of the ABCDE bundle is Delirium monitoring and management.
Every patient admitted to an adult ICU will undergo routine sedation & delirium assessment using standardized, validated assessment tools
A RN will administer & record the results of the RASS every 2 hours. Delirium assessment is actually part of the overall consciousness assessment. Consciousness is defined in two parts—arousal level plus content . The first step to assessing consciousness is to assess level of consciousness. This is best done using a validated sedation/arousal scale.
A RN will administer and record the results of the CAM-ICU every eight hours & whenever a patient experiences a change in mental status
Each day during interdisciplinary rounds, the team will set a “target” RASS score for the patient to be maintained at for the following 24 hours

22. What is the CAM-ICU? So what is the CA-ICU? TheWhat is the CAM-ICU?
The Confusion Assessment Method (CAM) was created in 1990, and it was intended to be a bedside assessment tool usable by non-psychiatrists by Dr. Sharon Inouye to assess for delirium.1 The CAM-ICU is an adaptation of this tool for use in ICU patients (e.g., critically ill patients on and off the ventilator who are largely unable to talk). Delirium is defined in terms of four diagnostic features, and is deemed present when a patient has positive Feature 1 and Feature 2 and either Feature 3 or 4 (see CAM-ICU schematic on next page).
Patinet with a RASS -4 or -5 can not assess for delirium. All other patients you can.

23. Delirium Monitoring & Management
Brain Road Map
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
OK you have determined your patient is delirious, now what? First recognized that delirium is often a harbinger for “badness”. Meaning it often tells us there is something seriously wrong with our patients. Communicating delirium statust to all care providers and the pattients family is crcucial. How are we going to communicate our findings.Each day during interdisciplinary rounds, the RN will (above)
Each day during interdisciplinary rounds, the team will use the acronym “THINK” if a patient is CAM positive (delirious).
Toxic situations and medications: congestive heart failure, shock, dehydration, new organ failure (e.g., liver, kidney), deliriogenic medications
Examples of deliriogenic medications include benzodiazepines, anticholinergic medications, and steroids
Hypoxemia
Infection/sepsis (nosocomial), inflammation, immobilization
Non-pharmacological interventions (see below)
K+ or other electrolyte interventions.
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
Administer medications judiciously; avoid high-risk medications, Prevent/promptly and appropriately, treat infections, Prevent/promptly treat dehydration and electrolyte disturbances, Provide adequate pain control, Maximize oxygen delivery (supplemental oxygen, blood, and blood pressure [BP] support as needed), Use sensory aids as appropriate, Regulate bowel/bladder function, Provide adequate nutrition
Foster orientation: frequently reassure and reorient patient; utilize easily visible calendars, clocks, caregiver identification; carefully explain all activities; communicate clearly
Provide appropriate sensory stimulation: quiet room; adequate light; one task at a time; noise-reduction strategies
Facilitate sleep: back massage, warm milk or herbal tea at bedtime; relaxation music/tapes; noise-reduction measures; avoid awakening patient unless necessary
Foster familiarity: encourage family/friends to stay at bedside; bring familiar objects from home; maintain consistency of caregivers; minimize relocations
Maximize mobility: avoid physical and chemical restraints and urinary catheters; ambulate or mobilize patient early and often, Communicate clearly, provide explanations, Reassure and educate family, Minimize invasive interventions
Consider psychotropic medication only as a last resort
3. How did they get there?
Drugs

24. NONPHARMACOLOGIC APPROACHES TO PREVENTING & TREATING DELIRIUM
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

25. 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
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
The final component of the ABCDE bundle is early mobility. The question often arises as to who can participate in early mobility programs In the ICU. Patients are candidates for mobilization when they following minimum criteria are met (above)
Patients are candidates for mobilization when certain criteria are met (right)
Any other justification for not implementing the protocol must be written specifically by a licensed prescriber (e.g., unstable fracture, skin integrity issues).
The interdisciplinary care team assesses the patient's readiness for mobility. The team includes a Physical therapist (PT) who assesses the patient’s physical ability to participate, RN who assesses physiologic stability, RT who is responsible for maintaining the patient’s airway, Critical care physician confirms that there are no clinical contraindications to physical activity
Each patient is assessed upon admission to the unit & those who qualify immediately begin on the protocol. Those who are not eligible are reassessed during daily rounds. If activity has been halted due to an acute event the patient is reevaluated each day until the protocol can be reinstated.

26. Early Mobility Progression
Walking A
Short Distance
Standing at bedside and
sitting in chair
Each eligible patient is encouraged to be mobile twice a day, with the specific level of activity geared to his or her readiness. Patients progress through a three-step process, embarking on the highest level of physical activity they can tolerate, as outlined below:
Sitting on edge of bed: As a first step, the PT & RN helps patients sit at the edge of the bed with their feet planted on the floor or on a platform. A caregiver may support the patient from behind, but the position is discontinued after a few minutes if the patient cannot hold his or her torso upright. The goal is to maintain this position for 10 minutes with minimal support. The patient moves to the second step after accomplishing this goal twice.
Standing at bedside and sitting in chair: As a next step, the PT & RN helps the patient stand at the bedside, bear some weight (by lifting each leg), and pivot into a chair by the bed. The patient is encouraged to sit in the chair for as long as he/she can tolerate it, up to 2 hours. The patient moves to the next step after accomplishing this step twice.
Walking a short distance: The final step is for the care team to help the patient walk, beginning with a few steps (e.g., to the doorway) and ultimately reaching 200 feet. The PT, RT and the RN will verify optimal time for ambulation.
Use of the protocol ends when the patient is discharged from the ICU. Readiness for ICU discharge depends on clinical considerations, not the patient's ability to walk 200 feet.
This step is appropriate for patients who are still on sedation and/or critically ill, and for others for whom it is risky to leave the bed. Care team members stay with patients for as long as they can tolerate the position, monitoring the patients for physiological signs and symptoms of distress such as fatigue and/or changes in blood pressure, heart rate, respiratory rate, and oxygen saturation level.
If the patient is stable and awake, the care team departs after approximately 15 minutes, but checks in periodically; equipment allows all patients to be monitored from a central station. If the patient becomes disconnected or declines physiologically, the care team returns immediately. If the care team is concerned about the patient’s ability to tolerate the sitting position, they remain with the patient.
PT and/or the RN will contact the RT to coordinate a time for the first ambulation session the following day. The RT will enter an order as “Patient Ambulation by RCS” in the Hospital Information System (HIS), including the frequency of ambulation.
The healthcare team will inform the patient (and family/caregivers) the ambulation schedule/activity for the day. The RT will assemble the equipment necessary for patient ambulation and ensure the patient’s artificial airway is secure throughout ambulation. The RT will adjust ventilator settings and/or provide manual resuscitation based on patient’s tolerance during ambulation and reconnect or return the patient to the ventilator at the previously ordered settings after completion of the activity. The RT will also document in the medical record: tolerance, complications, and adjustments in ventilator settings, etc. The RN will monitor the patient’s HR, RR, SpO2, ETCO2 etc. The RN and PT support the patient; canes and walkers may be used as needed. A patient care technician will follow the patient with a wheelchair in case of fatigue or medical need and assists with other equipment as needed. For ventilated patients in contact isolation caregivers will wear clean appropriate isolation barriers (gowns, gloves, etc.) when ambulating the patient in the hallway. The RN will ensure the patient’s drainage is contained. The team will dedicate the equipment for the activity whenever practical and if reusable equipment is used, clean with low level disinfectant solution after use. The team will maintain a “no-touch” technique of all environmental surfaces when outside of the patient’s room.
Sitting on edge of bed

27. 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.
1. Central line-associated bloodstream infections were once considered part of the
unavoidable complications of ICU care.
2. Repeated studies demonstrate that RNs & RTs can successfully use sedation and mechanical ventilation protocols & streamline the process of care from a minimum of three separate processes to one unifying process. Although physician expertise
& judgment is critical in ICU management, mounting evidence suggests that a team-based, evidence-based, and systematic approach to care delivery is required.
3. ABCDE requires each team member to provide & receive constant bidirectional feedback facilitated by common assessment tools that describe complex constructs of sedation & delirium.

28. ABCDE SUMMARY POINTS ABCDE should become the default practice.
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.
4. Patients cannot afford to wait for physicians to make decisions regarding initiation of an SAT,
SBT, or physical therapy, especially when RNs and RTs may be present at the bedside more often and have an even better ability to manage processes of care and monitor for subsequent improvements or decline. ABCDE practices must be structured as a daily part of care with clearly laid out safety guidelines.
5. First, although sedative administration is a common practice, it may not always be required. Second, implementation of daily SATs and SBTs raises appropriate concerns about inadequate rest
and potential psychologic trauma, yet, to date there is no strong evidence to suggest either
occurs. Finally, in the case of protocolized exercise, not only did patients walk 5 days earlier when prompted by a protocol, but they did so without excess unplanned extubation or equipment removal.

29. University of Nebraska Medical Center
OUR GOAL!

30. THANK YOU !!!!!! University of Nebraska Medical Center