Applying the “ABCDE” Bundle into Clinical Practice

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. 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. 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

4. 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

5. 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. 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

9. University of Nebraska Medical Center OUR TEAM

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

11. 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

12. University of Nebraska Medical Center THE 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

13. 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

14. University of Nebraska Medical Center ABC “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

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? • 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

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: - 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? • 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

19. 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

20. 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 Dementia Acute brain dysfunction “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. 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

24. 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. 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

26. Early Mobility Progression Walking A Short Distance Standing at bedsideand sitting in chair 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.

28. 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.

29. University of Nebraska Medical Center OUR GOAL!

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