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The ABCDE (Awakening and Breathing Coordination, Delirium Monitoring and Management, and Early Mobility) is a comprehensive bundle that uses evidence based practice to promote interventions related to sedation and analgesia, delirium, immobility, and ventilator management in the intensive care unit. This project was completed at Adirondack Medical Center in Saranac Lake, NY. The purpose of this study was in regards to the ventilator management quality indicator. AMC intensive care unit is falling short of the National Patient Safety Goals. In the most recent quarterly analysis of quality indicators, AMC was compliant with ventilator management goals by only 67%. Additionally, a survey was used to evaluate both the nurse’s and respiratory therapists’ knowledge of sedation vacations, weaning from a ventilator, and the prevention of delirium in the ICU patient. The implications of this research show that an interdisciplinary team of nurses, physicians, respiratory therapists, and physical therapists need to form a wide-ranging protocol and procedure for ventilator management in the prevention of ventilator associated events. Within this protocol there will be a delirium prevention and assessment section. There is a need for this because there is no uniform and valid tool used to assess for ICU associated delirium at AMC. This project aimed to education the ICU nurses at AMC about iatrogenic delirium and the importance of optimal ventilator management.
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Awakening and Breathing Trial Coordination: Collaborative approach is necessary when administering sedation (type and amount), then allowing patient to wake up from sedation safely (key time fore reorienting patient), and finally assessing the patient’s ability to breathe by themselves by safely weaning them from the ventilator. These trial involve teamwork with physicians, nurses, respiratory therapists and pharmacists.
Delirium Assessment and Management: Daily monitoring for the presence of delirium, as well as addressing the presence of pain and agitation.
Early Progressive Mobility: Collaboration among the ICU staff and the Physical Therapy team is necessary. Mobility goals for patient must be assessed with safety of the patient as primary importance. Mobility of the patient should go from passive range of motion, to active range of motion, and eventually to ambulation of the patient.
Background and Definitions
Risks Associated with Prolonged VentilationProlonged ventilation is associated with an increased risk for VAE Ventilator (Associated Events), increased risk for pressure ulcers, skin breakdown, and muscle atrophy related to extended immobility, and increased risk for delirium.
CDC GuidelinesIn 2015 it was found that three ICU patients had a Ventilator Associated Condition (VAC). The Center for Disease Control and Prevention has designated three tiers to a Ventilator Associated Event. 1) Ventilator-Associated Condition (VAC); 2) Infection-related Ventilator-Associated Complication (IVAC); and 3) Possible VAP (PVAP). The use of this three tier method expands the surveillance of mechanically ventilated patients to include additional complications. Most VAEs are caused by pneumonia, pulmonary edema, atelectasis, or acute respiratory distress syndrome.
DeliriumDelirium impacts between 60 and 80 percent of mechanically ventilated patients in the U.S, but in many patients it goes undiagnosed and untreated. Prevention and early detection of delirium in ICU patients is key. Delirium can cause prolonged ventilator days and ICU stay, increased mortality rates, and increase risk for neuropsychological disorders such as Post Traumatic Stress Disorder. Delirium can also affect patients who are not mechanically ventilated.
Quality IndicatorsVentilator Management Quality indicators are significantly related to the implementation of or documentation of sedation vacation, also known as spontaneous awakening trials. At Adirondack Medical Center ICU, in the first quarter there were three ventilated patients and 100% compliance. In the second quarter there was 78% compliance, and sedation vacation was not implemented on two of the three eligible ventilated patients. In the third quarter there was 67% compliance, and sedation vacation was not implemented on one of two eligible ventilated patients.
Delirium Management
Answer Survey Question
75% - Ramsay Sedation Scale75% - Richmond Agitation Scale
Which sedation scale do you use to monitor sedation level? (Only nurses)
66.6% -Routinely33.3% -Sometimes
How often are sedation goals addressed in rounds for mechanically ventilated patients? (Both nurses and Respiratory Therapy)
66% - None16% - Don’t Know16% - General Assessment
What delirium assessment tool do you use? (Both nurses and Respiratory Therapy)
Kelly Martin
Discussion of ABCDE Bundle
Methods and Results
A literature review was completed and researched showed that an ABCDE bundle injunction with a VAE protocol is best practice. A nine question survey was administered to the nurses on the Intensive Care Unit and to the Respiratory Therapy department. A total of 6 surveys were received on Tuesday Nov 17th out of possible 20. 4 from the nurses and 2 from the respiratory therapist. One question asked the participants to review the attached delirium monitoring tools. 33% said they preferred the Intensive Care Delirium Screening Checklist Worksheet (ICDSC), 33% said they preferred the Confusion Assessment Method, 33% reported no answer.
The survey questioned nurses knowledge related to sedation vacation goals and exclusion criteria. Over 75% of respondents did not know proper exclusion criteria for implementing a sedation vacation. Additional teaching is required.The survey question respiratory therapy knowledge related to spontaneous breathing trial goals and exclusion criteria. Of the two respondents adequate responses were given.
Delirium is an acute change in level of consciousness, in conjunction with inattention, disorientation, hallucination, psychomotor changes, and inappropriate speech. All of these do not have to be present for a delirium diagnosis. Assessment of Delirium:
There are known risk factors associated with acute delirium. These include pre-existing dementia, hypertension, alcoholism, and severe admission diagnosis.
A uniform and valid tool should be used daily among ICU patients. These tools include the Confusion Assessment Method for the ICU (CAM-ICU) and the Intensive Care Delirium Screening Checklist (ICDSC). Patients on a ventilator should be assessed for delirium every 24 hours. Non-ventilator patients should be assessed for delirium if there is a known mental status change from baseline. Therapeutic Management of Delirium:
Stop, Think, and Medicate (if necessary)- Stop: Is targeted sedation being met? Is patient on any
benzodiazepines?- Think: Are there any potential causes of delirium
present? Toxic Situation, Hypoxemia, Infection and Immobility, Non-pharmacologic interventions (room with natural lighting, reorientation, hearing aids in place, adequate sleep schedule), K+ (what are the patient’s potassium levels)
-Medicate: Haloperidol and atypical antipsychotics occasionally prescribed for delirium. Primarily want to treat cause of delirium (for example elderly patients with UTI exhibits delirium symptoms).
ConclusionIn conjunction with the VAE protocol, the ABCDE bundle should be used to prevent delirium in the ICU. Increased staff knowledge on the signs and symptoms of delirium is imperative for its prevention and early detection in the ICU. For this bundle to be effective strong collaboration among interdisciplinary staff, such as nurses, physicians, respiratory therapy, and pharmacy must be made. Non-pharmacologic interventions such as reorientation to person, place, and time and use of natural light (when possible) should be used among all ICU patients.
The purpose of this project was to plan a Ventilator Associated Event protocol in response to the quality indicators. This policy will include best practices nurse and respiratory driven spontaneous awakening and breathing trials. Finally, there is no tool for the assessment of iatrogenic delirium in the ICU. This tool will help in the prevention and early detection of ICU delirium.
Purpose
