Patients in intensive care units (ICUs) are often put on ventilators, sedated and/or immobilized for part of their stay. Unfortunately, all of these procedures can also put them at risk for delirium, which can be debilitating and have longterm negative effects. A new study published in Critical Care Medicine finds that implementing a set of practices to encourage patients’ mobility and reduce sedation effectively reduces delirium and the need for a ventilator and increases patients’ mobility during hospitalization, which decreases weakness.
The study, funded by the Robert Wood Johnson Foundation Interdisciplinary Nursing Quality Research Initiative (INQRI), tested the effectiveness and safety of implementing a bundled set of evidence-based practices into everyday practice in the ICU. It is called the ABCDE bundle, for Awakening and Breathing Coordination, Delirium monitoring and management and Early mobility.
The research team, led by Michele Balas, RN, PhD, APRN-NP, CCRN, assistant professor at the The Ohio State University, and William Burke, MD, professor of psychiatry and vice chair for research at the University of Nebraska Medical Center, examined the results of having a nurse-led interdisciplinary team use the bundle with roughly 150 patients in five adult ICUs, one step-down unit and an oncology/special care unit in a medical center and compared their outcomes with those of a similar group of patients in the same setting prior to implementation of the bundle.
Patients in the study who were managed with the ABCDE bundle spent more days breathing without a ventilator (a median of 24 days compared with a median of 21 days). Fewer of those patients experienced delirium, compared with the other group (48.7 percent compared with 62.3 percent), and delirium duration was reduced by one day. Patients treated with the bundle had twice the odds of getting out of bed at least once during their hospital stay, and lower hospital mortality (11.3 percent compared to 19.9 percent).
“Even though the team didn’t fully and consistently adhere to the bundle protocol, we saw significant differences in the two groups of patients,” said Balas. “And those differences make a difference over the long run for patients. Reducing delirium, increasing mobility and reducing reliance on the ventilator while a patient is in the hospital also reduces that patient’s weakness, reduces psychological stress and can help speed up recovery after discharge.”
The ABCDE bundle uses the best available evidence on delirium, immobility, sedation and analgesia, and ventilator management in the ICU. It is a bundle of interventions tested in clinical trials that have been adapted for everyday use in the ICU. The bundle is founded on three primary principles: improving communication among members of the ICU team, standardizing care processes and breaking the cycle of oversedation and prolonged attachment to a ventilator that can lead to delirium and weakness.
The ABCDE bundle, which was developed by E. Wesley Ely, MD, MPH; Eduard Vasilevskis, MD; and their colleagues at Vanderbilt University, includes nurse-implemented, protocol-directed sedation; daily interruption of a patient’s infusion of sedatives until the patient can follow simple commands or becomes agitated (spontaneous awakening trials); periodically taking a patient off a ventilator to breathe on his or her own (spontaneous breathing trials); screening patients for delirium using either the Confusion Assessment Method-ICU or the Care Delirium Screening Checklist; and introducing physical and occupational therapy as soon as possible. Ely and Vasilevskis served as consultants on this project.
“This study confirms that the ABCDE bundle, although complex, is an effective intervention for improving patient outcomes,” said Burke. “With this study, we also established that it is possible for a hospital team to safely implement this intervention on a daily basis in the ICU.”
The Interdisciplinary Nursing Quality Research Initiative is funded by the Robert Wood Johnson Foundation.
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