Applying the “ABCDE” Bundle into Clinical Practice Michele C. Balas PhD, APRN-NP, CCRN Assistant...
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Transcript of Applying the “ABCDE” Bundle into Clinical Practice Michele C. Balas PhD, APRN-NP, CCRN Assistant...
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
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 STORYWHAT 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 STORYWHAT 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 STORYWHAT 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 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
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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
University of Nebraska Medical Center
University of Nebraska Medical Center
Step 1 –SAT Safety Screen-RN Driven
SAT Safety Screen Questions1. 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
SAT Failure Questions1.RASS score > 2 for >5 minutes 2.Sa02 < 88 % for> 5 minutes3.Respirations >35 BPM for >5 minutes4.New Acute Cardiac Arrhythmia5.ICP >206.2 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
•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
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?
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
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 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
SBT Failure Questions1.Respirations >35/minute for > 5 minutes 2.Respiratory rate <83.Sp02 <88% 4.Mental status changes5.Acute cardiac arrhythmia6.ICP >207.2 or more of the following symptoms of respiratory distress: Accessory Muscle use, Abdominal Paradox, Diaphoresis, Dyspnea, Mental status changes, Acute cardiac arrhythmia
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”
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
Each day during interdisciplinary rounds, the RN will:
1.State the “TARGET” RASS score 2.State the patient’s ACTUAL RASS score3.State the CAM-ICU status4.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 RASSCurrent CAM-ICU
3. How did they get there?Drugs
Brain Road Map
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
Early Mobility-Safety Screen-RN Driven1. 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 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
Early Mobility Progression
WalkingA
Short Distance
Standing at bedsideand
sitting in chair
Sitting on edge of bed
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
University of Nebraska Medical CenterUniversity of Nebraska Medical Center
THANK YOU !!!!!!