Journal of Gerontological Nursing

Feature Article 

Extending the ABCDE Bundle to the Post-Intensive Care Unit Setting

Michele Balas, PhD, RN, APRN-NP, CCRN; Rose Buckingham, MSN, APRN, GNP-BC; Tami Braley, RN, BSN; Sarah Saldi, RN, BSN; Eduard E. Vasilevskis, MD

Abstract

A recently proposed interprofessional, evidence-based, multicomponent approach to mitigating the effects of intensive care unit (ICU)–acquired delirium and weakness has the potential to radically transform the way care is delivered to older adults requiring sedation, mechanical ventilation, or both. The Awakening and Breathing Coordination, Delirium Monitoring and Management, and Early Mobility (ABCDE) bundle empowers members of the interdisciplinary ICU team to implement the best available evidence regarding mechanical ventilation, sedation, weakness, and delirium in a safe, effective, and patient-centered manner. Considering that critically ill older adults are cared for in a number of different settings during the course of hospitalization and recovery, the purpose of this article is to explore the rationale and possible benefits of extending the ABCDE bundle into the post-ICU setting. We provide a case study that illustrates how ABCDE bundle adoption could be the key to improving the quality of care provided to seriously ill older adults in the ICU and beyond. [Journal of Gerontological Nursing, 39(8), 39–51.]

Dr. Balas is Assistant Professor, University of Nebraska Medical Center, College of Nursing, Department of Community Based Health; Ms. Buckingham is NICHE Coordinator, The Nebraska Medical Center, and Doctorate of Nursing Practice student, University of Nebraska Medical Center, College of Nursing; Ms. Braley is Clinical Research Coordinator, Clinical Research Center, The Nebraska Medical Center, and Adult-Gerontology Primary Nurse Practitioner student, University of Nebraska Medical Center, College of Nursing; Ms. Saldi is Gerontology Nurse Practitioner student, University of Nebraska Medical Center, College of Nursing; and Dr. Vasilevskis is Assistant Professor of Medicine, Department of Medicine, Division of General Internal Medicine and Public Health, Section of Hospital Medicine, Vanderbilt University, Center for Health Services Research, Veterans Affairs Tennessee Valley, Geriatric Research, Education and Clinical Center (GRECC), Nashville, Tennessee.

Dr. Balas is currently supported by an Alzheimer’s Association technology grant. Dr. Vasilevskis is supported by the National Institutes of Health (grant K23-AG040157) and by the Veterans Affairs Tennessee Valley GRECC. The remaining authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Michele Balas, PhD, RN, APRN-NP, CCRN, Assistant Professor, University of Nebraska Medical Center, College of Nursing, Department of Community Based Health, 985330 Nebraska Medical Center, Omaha, NE 68198-5330; e-mail: mbalas@unmc.edu.

Received: April 13, 2013
Accepted: May 07, 2013
Posted Online: June 10, 2013

Abstract

A recently proposed interprofessional, evidence-based, multicomponent approach to mitigating the effects of intensive care unit (ICU)–acquired delirium and weakness has the potential to radically transform the way care is delivered to older adults requiring sedation, mechanical ventilation, or both. The Awakening and Breathing Coordination, Delirium Monitoring and Management, and Early Mobility (ABCDE) bundle empowers members of the interdisciplinary ICU team to implement the best available evidence regarding mechanical ventilation, sedation, weakness, and delirium in a safe, effective, and patient-centered manner. Considering that critically ill older adults are cared for in a number of different settings during the course of hospitalization and recovery, the purpose of this article is to explore the rationale and possible benefits of extending the ABCDE bundle into the post-ICU setting. We provide a case study that illustrates how ABCDE bundle adoption could be the key to improving the quality of care provided to seriously ill older adults in the ICU and beyond. [Journal of Gerontological Nursing, 39(8), 39–51.]

Dr. Balas is Assistant Professor, University of Nebraska Medical Center, College of Nursing, Department of Community Based Health; Ms. Buckingham is NICHE Coordinator, The Nebraska Medical Center, and Doctorate of Nursing Practice student, University of Nebraska Medical Center, College of Nursing; Ms. Braley is Clinical Research Coordinator, Clinical Research Center, The Nebraska Medical Center, and Adult-Gerontology Primary Nurse Practitioner student, University of Nebraska Medical Center, College of Nursing; Ms. Saldi is Gerontology Nurse Practitioner student, University of Nebraska Medical Center, College of Nursing; and Dr. Vasilevskis is Assistant Professor of Medicine, Department of Medicine, Division of General Internal Medicine and Public Health, Section of Hospital Medicine, Vanderbilt University, Center for Health Services Research, Veterans Affairs Tennessee Valley, Geriatric Research, Education and Clinical Center (GRECC), Nashville, Tennessee.

Dr. Balas is currently supported by an Alzheimer’s Association technology grant. Dr. Vasilevskis is supported by the National Institutes of Health (grant K23-AG040157) and by the Veterans Affairs Tennessee Valley GRECC. The remaining authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Michele Balas, PhD, RN, APRN-NP, CCRN, Assistant Professor, University of Nebraska Medical Center, College of Nursing, Department of Community Based Health, 985330 Nebraska Medical Center, Omaha, NE 68198-5330; e-mail: mbalas@unmc.edu.

Received: April 13, 2013
Accepted: May 07, 2013
Posted Online: June 10, 2013

Older adults requiring mechanical ventilation (MV) are at risk for numerous adverse outcomes including increased short- and long-term mortality, profound neuropsychological impairment, substantial functional decline, and frequent readmission to hospitals and skilled nursing facilities (SNFs) (Barnato, Albert, Angus, Lave, & Degenholtz, 2011; Jackson et al., 2003; Wunsch et al., 2010). This increase in morbidity, mortality, and resource utilization contributes to the enormous human and societal costs associated with the provision of MV. It is estimated that by the year 2020 the expected annual hospital cost associated with MV for more than 96 hours will exceed $64 billion (Zilberberg & Shorr, 2008). Similarly, the number of discharges to SNFs for this same population is expected to exceed 200,000 in the year 2020, compared to 90,928 in the year 2000 (Zilberberg & Shorr, 2008). There is a clear need for interprofessional, evidence-based strategies aimed at reducing the frequency and complications associated with MV in the older adult population.

The Awakening and Breathing Coordination, Delirium Monitoring and Management, and Early Mobility (ABCDE) bundle is an evidence-based, interprofessional, multicomponent approach aimed at improving the quality of care and clinical outcomes of mechanically ventilated patients (Morandi, Brummel, & Ely, 2011; Pandharipande, Banerjee, McGrane, & Ely, 2010; Vasilevskis et al., 2010). The ABCDE bundle was proposed in recognition of the complex, interconnected relationship between MV, sedation, delirium, and weakness and their effect on patient outcomes (Figure). The ABCDE bundle seeks to reduce the risk for intensive care unit (ICU)–acquired delirium and weakness by reducing or removing sedation and MV therapy in a structured, standardized process, while simultaneously promoting delirium monitoring and early mobility (Vasilevskis et al., 2010). For example, patients historically received continuous infusions of sedative and analgesic agents in an attempt to prevent anxiety and pain, and provide amnesia, yet excessive doses and duration of some of these medications have also been linked to the development of ICU delirium (Jones & Pisani, 2012). In addition, over-sedation and the duration of MV are associated with immobility and the development of ICU-acquired weakness (Hopkins & Spuhler, 2009), which further contribute to physical, functional, and cognitive morbidity. Timely reduction and removal of each of these factors can be safely performed in a standardized way, to maximize benefit, without reported increases in harm.

The ABCDE bundle and its effect on patient outcomes. From “Facilitators and Challenges to Conducting Interdisciplinary Research,” by C.F. Corbett, L.L. Costa, M.C. Balas, W.J. Burke, E.R. Feroli, & K.B. Daratha, 2013, Medical Care, 51(4 Suppl. 2), S23–S31. Copyright 2013 by Wolters Kluwer Health. Reprinted with permission.

Figure. The ABCDE bundle and its effect on patient outcomes. From “Facilitators and Challenges to Conducting Interdisciplinary Research,” by C.F. Corbett, L.L. Costa, M.C. Balas, W.J. Burke, E.R. Feroli, & K.B. Daratha, 2013, Medical Care, 51(4 Suppl. 2), S23–S31. Copyright 2013 by Wolters Kluwer Health. Reprinted with permission.

Although the ABCDE bundle was originally intended to be used with critically ill MV patients, we believe an opportunity exists to extend its use beyond the ICU setting. We also argue that older adults, in particular, would benefit from a unified approach to preventing and managing delirium and weakness associated with surgery, serious illness, sedation, and/or previous MV. This article presents a clinical case study and discussion that illustrates how the framework of the ABCDE bundle could be applied by gerontological nurses outside the ICU setting.

Individual Example

Jim was a relatively healthy 83-year-old man without cognitive or functional impairment. While painting his barn, Jim fell off a 12-foot ladder onto a pile of firewood. The ambulance was called to his residence for complaints of severe left-sided chest pain and difficulty breathing. In the emergency department, a chest x-ray revealed multiple left-sided rib fractures without evidence of a pneumothorax. After receiving 4 mg of morphine sulfate (Avinza®), Jim rated his pain 8 of 10. The pain inhibited him from taking deep breaths, and his oxygen saturation on 2 liters nasal cannula was 92%. Because of his age, injuries, and oxygen requirements, Jim was admitted to a step-down unit for close monitoring.

Jim struggled with pain control issues for the first 24 hours of his step-down unit stay. After receiving multiple boluses of as-needed (PRN) morphine, Jim was started on intravenous (IV) hydromorphone via a patient-controlled analgesia pump. Although Jim’s pain control improved, it was still severe enough to prevent use of the inspiratory spirometer or engagement in physical activity. He also reported being extremely tired and unable to sleep. Jim’s nurse obtained an order for a medication to help him sleep and asked physical therapy (PT) to defer evaluating him until the pain was better controlled.

Jim’s mental and respiratory status deteriorated on Day 2. He became delirious with a “negative” computed tomography scan, his agitation worsened, and he received escalating doses of haloperidol (Haldol®) and lorazepam (Ativan®). This resulted in an episode of unresponsiveness, urgent airway intubation, and transfer to the ICU.

Eventually diagnosed with adult respiratory distress syndrome (ARDS), Jim required MV support and high doses of continuously infused narcotics and sedatives to maintain adequate oxygen saturation. After 1 week on the ventilator, Jim began to make steady progress but received a tracheostomy to facilitate ventilator weaning. Nursing staff asked PT to defer seeing Jim, as the physician had ordered him to be on bed rest, and they were still having a hard time keeping him calmly sedated on continuous sedative and analgesic drips. Because of the severity of his initial lung injury, the physicians decided to wean him from the ventilator “slowly.” On Day 10 of his ICU stay, all continuous sedative drips were discontinued, and he was changed to PRN lorazepam, haloperidol, and morphine. Jim remained on bed rest throughout his ICU stay and was eventually transferred to a long-term acute care hospital (LTACH) for MV weaning.

During his time in the LTACH, Jim vacillated between periods of agitation and lethargy. The LTACH did not use standardized delirium and/or sedation screening instruments, and staff assumed that Jim’s cognitive problems were chronic in nature. He had PRN orders for lorazepam, morphine, haloperidol, diphenhydramine (Benadryl®), and quetiapine (Seroquel®) continued from the hospital, all of which were given at the frequency allowed. His medication regimen included a total of 20 regularly scheduled and PRN medications. Jim consistently lay in bed all day in a darkened room, not eating and not participating in therapy or engaging with nursing staff. At times, he did not even acknowledge the presence of his wife. He was unable to make progress weaning from the MV and 20 days after LTACH admission, Jim passed away from presumed pulmonary emboli.

The ABCDE Bundle in the ICU

Stories of lost opportunities, such as Jim’s, are unfortunately common in our often fragmented health care system. A primary focus of the ABCDE bundle is to recognize the importance of improving the “back-end” of critical care (Pandharipande et al., 2010). When patients no longer need them, what was initially a life-saving intervention can quickly transform into iatrogenic injuries that include acute and chronic cognitive and functional impairments. The ABCDE bundle in the ICU is structured in a way to reduce the potential for iatrogenic injury by means of: (a) standardizing and coordinating care processes that synergistically reverse the cycle of over-sedation, MV, and immobilization; (b) empowering nurses, respiratory therapists, and PTs to manage those care processes; and (c) ensuring that these processes are the default option, unless clear safety concerns preclude completion (Vasilevskis et al., 2010). A description of these processes in the ICU setting is provided in Table 1 and has been discussed more fully in a previous article (Balas, Vasilevskis, et al., 2012).

Application of the ABCDE Bundle in the Intensive Care Unit (ICU) SettingApplication of the ABCDE Bundle in the Intensive Care Unit (ICU) SettingApplication of the ABCDE Bundle in the Intensive Care Unit (ICU) Setting

Table 1: Application of the ABCDE Bundle in the Intensive Care Unit (ICU) Setting

The “A” in the ABCDE bundle acronym stands for awakening. Both sedative and opioid medications possess deliriogenic properties (Patel & Kress, 2012), and their over-use is associated with numerous adverse outcomes, including an increase in the duration of MV, prolonged length of stay, risk of nosocomial complications, and need for additional diagnostic testing (Jacobi et al., 2002; Kollef et al., 1998). According to the American College of Critical Care Medicine (ACCM) guidelines for the sustained use of sedative and analgesic agents in critically ill adults, both pain and sedation should be regularly documented and assessed using valid and reliable tools. The ICU team should establish a regularly defined sedation goal for each patient (Jacobi et al., 2002).

One possible strategy for accelerating recovery in patients like Jim is the regular interruption of sedative and opioid infusions. The use of spontaneous awakening trials (SATs), or holding continuous sedative infusions once per day until the patient was “awake,” was found to lead to statistically significant reductions in both the duration of MV and ICU length of stay (Kress, Pohlman, O’Connor, & Hall, 2000). Importantly, the use of SATs was not associated with posttraumatic stress disorder (PTSD), cardiac ischemia, increased rates of agitation-related complications, or self-device removal (Kress et al., 2000, 2003, 2007), suggesting SATs are safe for everyday clinical practice.

In Jim’s case, it is probable that the medications he received both during his ICU stay and in the LTACH contributed to his altered mental status and need for prolonged MV. Jim’s struggle with pain during his pre-ICU period also likely contributed to his lack of sleep, inability to perform incentive spirometry, reluctance to participate in PT, and eventually provoked the administration of non-opioid sedative agents. All of these factors likely contributed to the development of ARDS and need for MV. If the interdisciplinary team communicated more effectively and explored alternative means of pain control (e.g., patient-controlled epidural anesthesia), it is possible this vicious cycle may have been interrupted. Although we acknowledge that Jim may have needed continuous infusions of sedative and narcotic agents during fulminant ARDS, we believe an opportunity existed to reduce the amount of sedative agents by using SATs once his pulmonary condition began to improve.

The “B” in the ABCDE bundle acronym stands for breathing. To reduce delays that contribute to prolonged MV, pneumonia, and airway trauma, the term “weaning” is replaced by “discontinuation” (MacIntyre et al., 2001). A strategy to facilitate MV discontinuation in patients like Jim is the use of spontaneous breathing trials (SBTs). An early randomized controlled trial that explored the effect of a respiratory care–driven weaning protocol using SBTs compared to routine care found that patients treated with the SBT protocol were significantly more likely to have shorter duration of MV and were less likely to require reintubation or prolonged MV (Ely et al., 1996).

The “C” in the ABCDE bundle acronym stands for coordination. The use of interdisciplinary protocols to guide MV discontinuation in patients like Jim is increasingly common. Given that SATs and SBTs were both found to reduce the duration of MV, Girard et al. (2008) studied the effect of combining SATs and SBTs versus routine sedation and SBTs. Patients treated with the pairing experienced more ventilator-free days, were discharged from the ICU and hospital earlier, spent less days in a coma, and were more likely to be alive at 1 year compared to controls. In Jim’s case, this pairing would have occurred once he was able to pass both the SAT and SBT safety screens (Table 1).

The “D” in the ABCDE bundle acronym stands for delirium monitoring and management. Affecting up to 80% of all MV ICU patients (Ely et al., 2004), delirium is associated with numerous adverse outcomes including prolonged hospital stay, post-discharge institutionalization, more days requiring MV, increased risk of death, higher costs, and neurocognitive decline (Jones & Pisani, 2012; Leslie, Marcantonio, Zhang, Leo-Summers, & Inouye, 2008). The evidence strongly suggests that both minimization of sedation and choice of agent may affect delirium occurrence and persistence (Patel & Kress, 2012). Medications associated with the development and/or persistence of ICU delirium include benzodiazepine agents, opioid agents, and haloperidol, many of which Jim received during his hospitalization (Jones & Pisani, 2012).

The ACCM’s current guidelines recommend ICU providers perform routine delirium assessment (Jacobi et al., 2002), because without active monitoring, delirium goes undiagnosed in up to 72% of cases (van Eijk et al., 2011). Two of the most frequently used, valid, and reliable delirium assessment tools in the ICU setting are the Confusion Assessment Method (CAM)-ICU (Ely et al., 2001) and the Intensive Care Delirium Screening Checklist (ICDSC) (Bergeron, Dubois, Dumont, Dial, & Skrobik, 2001). Once patients like Jim are screened, the results of the delirium assessment should be communicated on daily interdisciplinary rounds where the team can then focus on identifying potential causes and treatment strategies (Balas, Vasilevskis, et al., 2012).

The “E” in the ABCDE bundle stands for early mobility. Bed rest is associated with numerous adverse effects including pressure ulcers, atelectasis, pneumonia, orthostatic intolerance, and decreased insulin sensitivity and substantial neuromuscular weakness that is common, persistent, and severe (Truong, Fan, Brower, & Needham, 2009).

Early mobilization is intended to mitigate the effects of ICU-acquired weakness. Schweickert et al. (2009) studied the effect of combining SATs with PT- and occupational therapy–assisted exercise and mobilization. Compared to patients receiving routine care, patients receiving early mobilization were found to be much more likely return to independent functional status at hospital discharge and experienced more ventilator-free days. Mobilized patients also had shorter duration of delirium (2 days versus 4 days). This finding is particularly important considering that in a critically ill older population each day spent delirious increases the risk of death within 1 year by 10% (Pisani et al., 2009).

Extending The ABCDE Bundle to the Post-ICU Setting

Older adults like Jim who are recovering from or receiving prolonged MV are cared for by gerontological nurses in a variety of post-ICU settings including the general medical/surgical ward, LTACHs, SNFs, rehabilitation centers, and home care (Unroe et al., 2010). For many of these patients, the time of ICU discharge is a particularly chaotic and potentially error-prone period. Gerontological nurses can ease this transition through careful assessment of need and application of the ABCDE bundle.

It is essential that nurses in the critical care and post-ICU settings communicate with each other about events that took place during their patient’s ICU stay. In terms of awakening, a discussion of what kind of sedative, antipsychotic, and pain medications the patient received is particularly relevant. For breathing, the nurses should focus on what discontinuation strategies were used to date, the patient’s response to the treatment, ongoing risks to the airway (e.g., secretions, dysphagia), and possible reasons for ventilator dependence (i.e., nutritional status, chest x-ray findings). The contribution of other disciplines, in terms of care coordination and planning, should be discussed. Delirium occurrence, duration, and treatment during the ICU stay are important factors to relay. Finally, the patient’s mobility level and exercise tolerance should be communicated. Table 2 provides further examples of questions to facilitate the transfer of care of patients to the post-ICU setting. The following section offers suggestions regarding use of the ABCDE bundle outside the ICU setting.

ABCDE Bundle-Prompted Questions to Facilitate Care Transitions

Table 2: ABCDE Bundle-Prompted Questions to Facilitate Care Transitions

Awakening

Patients like Jim rarely receive continuous IV sedation outside the ICU. The use of PRN medications to treat pain, anxiety, and delirium, however, is common throughout care settings. Because of the benefits associated with sedation minimization, we believe patients in the post-ICU setting should also undergo daily “awakening” trials. Similar to SATs, this awakening period should be guided by a process that helps the nurse determine first if it is “safe” to discontinue sedative medications and then objectively defines what an awakening “failure” means. This process should be guided by the use of valid and reliable sedation and pain assessment scales (Riker, Picard, & Fraser, 1999; Sessler et al., 2002). Because of their training and expertise, gerontological advanced practice nurses (APNs) are ideally suited to take the lead on providing the education the interprofessional team will need to successfully implement these tools into everyday practice.

Benzodiazepine agents, antipsychotic agents, and medications with anticholinergic properties should be considered particularly high risk in the older adult population (American Geriatrics Society Beers Criteria Update Expert Panel, 2012; Morandi, Brummel, et al., 2011). In addition to being potentially deliriogenic, there is evidence that their administration actually interrupts the restorative function of normal sleep (Weinhouse & Watson, 2009). Successfully implemented nonpharmacological sleep strategies (e.g., unit-wide noise reduction strategies, relaxation recordings, massage, ear plugs) to promote daytime awakening are therefore warranted (Inouye et al., 1999; Mudge, Maussen, Duncan, & Denaro, 2012). A pharmacy consult or use of computer-based alert system (Agostini, Concato, & Inouye, 2007) to proactively identify these poorly tolerated, high-risk medications may also be appropriate.

Analgesic agents remain the cornerstone of acute pain management for older adults. Scheduling nonopioid pain medications around-the-clock and initiating analgesia prior to surgery may be helpful strategies to decrease overall opioid agent requirements (Herr, Bjoro, Steffensmeier, & Rakel, 2006). The analgesia-first (or A1) strategy is gaining popularity and may be another option in the care of ICU survivors at high risk of cognitive and functional impairment. With the A1 approach, sedating medications are given only after aggressive analgesic agent strategies are implemented. This strategy has been linked with faster MV discontinuation and more consistent achievement of comfort goals (Riker & Fraser, 2009). Finally, the importance of medication reconciliation at the time of ICU and hospital discharge cannot be overemphasized. One study found that 50% of inappropriate medications continued at the time of hospital discharge were originally started in the ICU (Morandi, Vasilevskis, et al., 2011). This study also noted that many of the antipsychotic agents started for delirium in the ICU are often continued in the post-ICU setting without a clear indication.

Awakening in the non-ICU setting could also be facilitated by the gerontological nurse by involving the patient in cognitively stimulating activities during the daytime hours. The Activity and Cognitive Therapy in the Intensive Care Unit study (Brummel et al., 2012) is currently exploring the effect of physical and twice-daily cognitive rehabilitation sessions on critically ill patient outcomes. The cognitive rehabilitation sessions, which will take place in the ICU, consist of orientation, memory, and attention exercises. The use of orientation and communication boards, clocks, acceptable levels of lighting, games, and laptop computers are also strategies nurses and family members may wish to employ (Balas, Rice, et al., 2012).

Breathing

Older survivors of critical care are at very high risk of developing respiratory complications throughout their recovery period. These complications frequently trigger the need for rapid response team calls and are a major factor for the high ICU recidivism rates in the older adult population (Rosenberg, Hofer, Hayward, Strachan, & Watts, 2001). Prolonged MV, over-sedation, aspiration, poor oral health, and age-related changes are known risk factors for the development of ventilator-associated pneumonia (Casey & Balas, 2011). Preexisting respiratory disease and postoperative hypoxia also place patients at higher risk for developing delirium (Aldemir, Ozen, Kara, Sir, & Bac, 2001). Because of these issues, we strongly recommend respiratory therapy play an active role in the daily evaluation and treatment of older adult ICU survivors, especially in the immediate period following ICU discharge, regardless of the primary ICU diagnosis.

In patients requiring prolonged MV, we suggest respiratory therapists take a lead role in determining the potential etiology of ventilator dependence. The use of a daily checklist that describes the potential causes of ventilator dependence may help standardize this process. The Evidence-Based Guidelines for Weaning and Discontinuing Ventilator Support provide six broad causes of ventilator dependency including: (a) neurological issues; (b) respiratory system muscle/load interactions; (c) metabolic factors and ventilator muscle function; (d) gas exchange; (e) cardiovascular factors; and (f) psychological factors, on which the checklist could be based (MacIntyre et al., 2001). Evidence suggests that implementation of a respiratory therapist–driven protocol for weaning patients from prolonged MV in the post-ICU setting can be effective in reducing the duration of MV. One study using such a protocol found the time to successful weaning was reduced from 29 to less than 17 days (Scheinhorn, Chao, Stearn-Hassenpflug, & Wallace, 2001).

A formal respiratory therapist assessment of pulmonary status at the time of ICU discharge (similar to a safety screen) can be useful in determining which patients will benefit from more aggressive pulmonary management in the post-ICU setting. A recent study of 3,113 patients discharged from a medical-surgical oncological ICU examined the impact of a respiratory therapist assessment score (RTAS) and respiratory therapy transitional service (RTTS) on ICU readmission rates (Bolden et al., 2006). All patients who underwent at least 24 hours of MV, noninvasive positive pressure ventilation, or were being discharged from the ICU with a FiO2 requirement >40 were included in the study. Of the 1,608 patients in the post-RTTS period, 240 patients met criteria for RTTS follow up. The ICU readmission due to respiratory causes before and after RTTS implementation were 58 (97%) and 2 (3%), respectively. These findings suggest there may be a substantial benefit from more aggressive respiratory therapy management of ICU survivors in the post-ICU setting.

Older adult survivors of critical care also experience complications related to intubation. Dysphagia, a common complication after intubation, carries a seven-fold increased risk of aspiration pneumonia and is an independent predictor of mortality (Singh & Hamdy, 2006). When coupled with the lethargy that often accompanies delirium, survivors are at elevated risk for aspiration pneumonia and its sequealae. For these reasons, we suggest that “breathing” in the post-ICU period should also entail obtaining a speech language pathologist consult for dysphagia evaluation and routine implementation of aspiration precautions.

Delirium Monitoring and Management

Delirium is a complex, under-recognized, serious, and commonly encountered syndrome in the post-ICU setting (Inouye, 2006). The incidence of delirium outside the ICU ranges from 6% to 56% (Yang et al., 2009). We recommend delirium monitoring continue throughout the post-ICU period to facilitate recognition and treatment by routine screening (i.e., every 8 hours) using the CAM-ICU or ICDSC (Bergeron et al., 2001) for non-vocal patients and the CAM (Inouye et al., 1990) with speaking patients. All of these tools are quickly and easily administered and have been shown to be valid and reliable in numerous studies and patient populations.

Similarly, the patient’s delirium status in the post-ICU setting should be discussed daily on interprofessional rounds where providers should identify, and if possible remove, possible causes of delirium (Balas, Vasilevskis, et al., 2012). Risk factors for delirium in older adults outside the ICU include preexisting cognitive impairment, vision and hearing impairment, immobilization, psychoactive medication use, dehydration, and sleep deprivation (Inouye, Bogardus, Baker, Leo-Summers, & Cooney, 2000). Although there are a number of nonpharmacological interventions nurses can independently implement (Balas, Rice, et al., 2012), the evidence strongly suggests that interprofessional, multicomponent delirium care models such as the Hospital Elder Life Program are most effective at reducing the frequency and duration of delirium (Inouye et al., 2000).

Early Mobility

Hospitalized adults spend 83% of their time in bed and only 4% standing or walking (Brown, Redden, Flood, & Allman, 2009). Considering the previously described hazards of immobility, we suggest that ambulation protocols be used in all post-ICU settings. Implementation of the protocols should be automatic, meaning all patients should be mobilized unless there are specific reasons for not doing so. Contraindications for progressive mobility could be placed in a mobility safety screen checklist. This “opt-out” approach may be a paradigm shift for some institutions that currently require a physician order for mobility status. However, a recent integrated review of the literature found that early mobilization (especially early ambulation) of medical-surgical patients was associated with improved outcomes for patients with deep vein thrombosis, reduced length of stay in patients with community-acquired pneumonia, and maintained or improved functional status from admission to discharge of hospitalized older adults and patients recovering from major surgery (Pashikanti & Von Ah, 2012). The greatest impact of early mobilization was through standardized mobility protocols or programs. Finally, the mobility protocols should be progressive in nature and based on the patient’s response to treatment.

Coordination of Care

We believe extension of the ABCDE bundle in the post-ICU setting will continue a focus on interprofessional communication and patient-centered care and therefore will improve the transition between the ICU, hospital, and home or institutional care. Effective implementation of the ABCDE bundle is entirely dependent on an institution’s commitment to reversing the hidden epidemics of delirium, immobility, poor transitions of care that exist in hospitals, and the ability to work across disciplines for these conditions that cut across training and specialty. A number of organizations, including the Institute for Healthcare Improvement, the National Quality Forum, and the Joint Commission, continue to emphasize the importance of communication and teamwork training in the delivery of safe, quality, patient-centered care. Models such as TeamSTEPPS® (available at http://teamstepps.ahrq.gov) help provide higher quality, safer patient care by producing highly effective medical teams that optimize the use of information, people, and resources to achieve the best clinical outcomes for patients; increasing team awareness and clarifying roles and responsibilities; resolving conflicts and improving information sharing; and eliminating barriers to quality and safety. We believe gerontological APN leadership is a necessary component to successful care coordination and smooth transitions.

Conclusion

The number of older adults being cared for in ICUs is expected to increase to unprecedented numbers in the very near future. These older adults are at risk for developing numerous complications during their hospitalization, many of which are now believed to be preventable. The ABCDE bundle was originally proposed to combat preventable harm related to MV, sedation, delirium, and immobility, yet the need for continued focus on cognition, respiratory function, and mobility are equally important following ICU discharge. Successful implementation of the individual components of the ABCDE bundle in the post-ICU setting will require gerontological nursing leadership, effective teamwork, clear communication, an environment committed to patient safety and best practices, and ways of monitoring both outcomes and processes of care. Overcoming these challenges by applying the ABCDE bundle in post-ICU settings will result in positive returns in the form of improved satisfaction and outcomes of patients, family, and staff.

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Application of the ABCDE Bundle in the Intensive Care Unit (ICU) Setting

Step 1—Spontaneous Awakening Trial (SAT) Safety Screen (RN-Driven)
• RN determines if it is safe to interrupt sedation by responding to a set of predefined safety screen questions.
• If determined safe, the RN proceeds to Step 2.
• If not safe, the RN will:
  Continue sedative and analgesic infusions as ordered.
  Discuss on interdisciplinary rounds (IDRs) possible reasons for SAT safety screen failure.
  Reevaluate the patient within the next 24 hours.
Step 2—Perform SAT (RN-Driven)
• RN shuts off all continuous sedative and analgesic infusions.
  All as-needed (PRN) sedatives are held.
  PRN analgesics allowed if needed for pain.
  Analgesic drips continued only if patient is actively experiencing pain.
• RN determines if patient tolerated interruption of sedation by assessing for a set of predefined SAT failure criteria.
• If no SAT failure criteria are displayed and the patient is able to open his/her eyes to verbal stimulation, the RN will:
  Contact the respiratory therapist (RT) and inform him/her the patient passed the SAT.
• If after 4 hours no SAT failure criteria are displayed but the patient is unresponsive to verbal stimulation, the RN will:
  Contact the RT and inform him/her the patient passed the SAT.
• If the patient displays any of the failure criteria, the RN will:
  Conclude that the SAT trial has failed.
  Resume sedation at half the previous dose, only if needed.
  Titrate sedation to daily goal.
  Discuss on IDRs possible reasons for SAT safety screen failure.
  Reevaluate the patient within the next 24 hours.
Step 3—Spontaneous Breathing Trial (SBT) Safety Screen (RT-Driven)
• RT determines if it is safe to perform an SBT by responding to a set of predefined safety questions.
• If determined safe, the RT will proceed to Step 4.
• If not safe, the RT will:
  Continue mechanical ventilation as ordered.
  Communicate findings to the RN.
  Ask the RN to resume sedation at half the previous dose, only if needed.
  Discuss on IDRs possible reasons for SBT safety screen failure.
  Reevaluate the patient within the next 24 hours.
Step 4—Perform SBT (RT-Driven)
• RT performs SBT.
• RT determines if patient tolerated SBT by assessing for a set of predefined SBT failure criteria.
• If no SBT failure criteria are displayed after ½ hour, the RT will:
  Contact the RN and physician to inform them the patient passed the SBT.
  Plan for patient extubation.
• If the patient displays any of the failure criteria, the RT will:
  Conclude that the SBT trial has failed.
  Return the patient to previous mechanical ventilation settings.
  Inform the RN the patient has failed the SBT.
  Ask the RN to resume sedation at half the previous dose, only if needed.
  Discuss on IDRs possible reasons for SBT safety screen failure.
  Reevaluate the patient within the next 24 hours.
Step 5—Delirium Monitoring and Management (RN, RT, Physician, and Pharmacist-Driven)
• Each day on IDRs, the ICU team will set a target sedation level.
• RN assesses sedation/agitation level every 2 hours using valid and reliable tool.
• RN titrates continuous sedative drips to target sedation level.
• RN performs delirium screening once per shift and notes any change in mental status using a valid and reliable tool.
• Each day on IDRs, the RN will present the team with:
  Patient’s target sedation level.
  Patient’s actual sedation level.
  Patient’s delirium status.
  Patient’s exposure to sedative, analgesic, and other deliriogenic medications.
• For patients experiencing delirium, each day on IDRs the team will:
  Identify possible causes of delirium.
  Eliminate all possible causes of delirium.
  Employ all nonpharmacological means necessary to reduce the duration of delirium.
  In the event the above interventions fail to return the patient to his/her baseline mental status, discuss possible pharmacological interventions.
Step 6—Early Mobility (RN, RT, PT, and OT-Driven)
• RN determines if it is safe to begin mobilization by responding to a set of predefined safety screen questions.
• If not safe, the RN will:
  Discuss on IDRs reasons for early mobility failure.
  Reevaluate the patient within the next 24 hours.
• If determined safe, the RN will:
  Contact the PT, OT, and RT to inform them that the patient passed the early mobility safety screen.
  Collaborate with the PT, OT, and RT as to when to best mobilize the patient that day.
  Assist the PT, OT, and RT with the implementation of the early mobility plan.
• Patients should be mobilized at a minimum of once per day.
• Progressive approach of sitting on edge of bed, standing at bedside, and sitting in chair, followed by ambulation, may be warranted.
• Assess patient’s tolerance of plan.

ABCDE Bundle-Prompted Questions to Facilitate Care Transitions

A—Awakening
• What type of sedative, antipsychotic, and pain medications did the patient receive during the ICU stay?
• Which are to be continued and for how long?
• How frequently were the above medications given to the patient?
• What behaviors did the patient display that prompted medication administration?
• What effect did the medications have on the patient’s behavior?
• Were the medications noted to have any undesirable side effects?
B—Breathing
• What discontinuation strategies were used during the patient’s ICU stay?
• What was the patient’s response to the discontinuation attempts?
• What possible reasons does the patient have to explain his/her ventilator dependence (e.g., nutritional status, chest x-ray findings)?
• How did the patient communicate his/her needs while on the ventilator?
• Does the patient experience dysphagia? Has a formal dysphagia screen been performed?
• Has the patient’s diet been modified to match any risk of aspiration?
C—Coordination
• Which disciplines were involved in the patient’s ICU care?
• What were their specific recommendations?
• Does the nurse believe other specialists are warranted?
D—Delirium Monitoring and Management
• What was the delirium and sedation status at the time of ICU transfer?
• Was the patient ever delirious during the ICU stay?
• If so, what was believed to have caused the delirium?
• What interventions were used to treat the delirium?
• Did the patient display hypoactive, hyperactive, or mixed delirium?
E—Early Mobility
• Did the physical and/or occupational therapist see the patient while he/she was in the ICU?
• If so, what were their recommendations?
• Is the patient able to ambulate?
• If yes, what type of assistance does the patient need to ambulate?
• What is the short- and long-term functional status goal?

Keypoints

Balas, M., Buckingham, R., Braley, T., Saldi, S. & Vasilevskis, E.E. (2013). Extending the ABCDE Bundle to the Post-Intensive Care Unit Setting. Journal of Gerontological Nursing, 39(8), 39–51.

  1. The principles of intensive care unit (ICU) delirium and weakness prevention in the ABCDE bundle should be continued to the post-ICU environment.

  2. Structured communication between care providers is needed to address cognitive, respiratory, and functional risks experienced by patients who transition from the ICU to the medical or surgical floor.

  3. At the time of ICU transfer and daily throughout the hospital stay, providers must address the ongoing need and indication for high-risk sedative, analgesic, and antipsychotic medications.

  4. All patients transferred from the ICU should receive ongoing progressive mobility protocols unless providers “opt-out” for explicit reasons of patient safety.

10.3928/00989134-20130530-06

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