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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.

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Presentation on theme: "Applying the “ABCDE” Bundle into Clinical Practice Michele C. Balas PhD, APRN-NP, CCRN Assistant Professor University of Nebraska Medical Center College."— Presentation transcript:

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 Delirium % non-MV ICU % MV ICU % S/T/B ICU ICU Acquired Weakness (AW) % of all patients who receive MV for 4-7 day % sepsis patients University of Nebraska Medical Center

3 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

4 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

5 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

6 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

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

8 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

9 OUR TEAM University of Nebraska Medical Center

10 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

11 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

12 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

13 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

14 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

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16 Step 1 –SAT Safety Screen-RN Driven SAT Safety Screen Questions 1.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

17 SAT Failure Questions 1.RASS score > 2 for >5 minutes 2.Sa0 2 5 minutes 3.Respirations >35 BPM for >5 minutes 4.New Acute Cardiac Arrhythmia 5.ICP > 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

18 SBT Safety Screen Questions 1.Is patient a chronic/ventilator dependent patient? 2.Is patient SpO 2 <88%? 3.Is patient’s FiO 2 >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

19 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 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 Questions 1.Respirations >35/minute for > 5 minutes 2.Respiratory rate <8 3.Sp02 <88% 4.Mental status changes 5.Acute cardiac arrhythmia 6.ICP > or more of the following symptoms of respiratory distress: Accessory Muscle use, Abdominal Paradox, Diaphoresis, Dyspnea, Mental status changes, Acute cardiac arrhythmia

20 WHY IS DELIRIUM SO CONFUSING? University of Nebraska Medical Center 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”

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

22 What is the CAM-ICU?

23 Delirium Monitoring & Management Each day during interdisciplinary rounds, the RN will: 1.State the “TARGET” RASS score 2.State the patient’s ACTUAL RASS score 3.State the CAM-ICU status 4.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 RASS Current CAM-ICU 3. How did they get there? Drugs Brain Road Map

24 NONPHARMACOLOGIC APPROACHES TO PREVENTING & TREATING DELIRIUM USE MEDICATIONS ONLY IF ABSOLUTELY NECESSARY!!!!!!!!!!!!!!!! Give “PEACE” a chance Physiologic Environmental ADLs/Sleep Communication Education University of Nebraska Medical Center

25 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 FIO 2 <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

26 Early Mobility Progression Walking A Short Distance Standing at bedside and sitting in chair Sitting on edge of bed

27 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

28 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

29 OUR GOAL! University of Nebraska Medical Center

30 THANK YOU !!!!!!


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