Alba I Gonzalez, MSN, RN, CCNS Florida Hospital Cardiovascular Institute

Alba I Gonzalez, MSN, RN, CCNS Florida Hospital Cardiovascular Institute

You treat a disease, you win, you lose. You treat a person, I guarantee you, you'll win, no matter what the outcome

Discuss an overview of clinical-based support, implementing the ABCDE bundle to patient care and implications for patient Describe the benefits and outcomes associated with the ABCDE bundle Define components of the ABCDE Bundle Examine elements that promote a change of culture Identify roles of the interdisciplinary team members in the implementation of the ABCDE Bundle

An inter-professional bundled approach to prevent ICU-acquired delirium and weakness Multiple evidence-based components that, when performed collectively and reliably, improve patients outcomes. The components are interdependent Balas et al. (2012). Critical Care Nurses Role in Implementing the ABCDE Bundle. Critical Care Nurse

Balas, et al., (2014) ccm Journal. Vol 42(5) 3 days less on MV!! ABCDE Component Pre ABCDE (N=146) Post ABCDE (N=150) Adjusted p ABC* Vent days Free-Mean (SD) 15 (11.4) 18 (10.6) N=296 Delirium Monitoring Delirium Anytime n (%) 91 (62.3%) 73 (48.7%) Duration of delirium, days median 3 (1-6) 2(1-4) P = 0.03 Mobilized out of bed n (%) 70 (48%) 99 (66%) P=0.003 28-day mortality Hospital Mortality n (%) ICU Mortality n (%) 29 (19.9%) 24 (16.4%) 17 (11.3%) 14 (9.3%) P=0.09 Discharged to Home n (%) 51 (44%) 60 (45.1%)

Awakening and Breathing Coordination

Stakeholders: Action A=Awakening SAT=Spontaneous Awakening Trial RN or MD Reduce or Eliminate Sedatives B=Breathing SBT=Spontaneous Breathing Trial RT or MD Discontinuation of active ventilatory support through T-Tube (rate of 0) C=Coordination of Care SBT follows SAT in a timely manner. RN and RT Coordinate appropriateness and timing of SABT

www.icudelirium.org

Myths 1. All Mechanically Ventilated ICU Patients Require Sedatives 2. It Is Easier to Care for Deeply Sedated ICU Patients 3. Sedatives Help to Facilitate Sleep in ICU Patients 4. Daily Interruptions of Sedative Medications Are Unsafe Peitz, et al., (2013). Top 10 Myths Regarding Sedation and Delirium in the ICU. CCMjournal. 41(9)

Sustained use of sedatives can prolong mechanical ventilation Increase ICU length of stay (LOS) increase the likelihood of developing acute delirium Riker, et al; SEDCOM (Safety and Efficacy of Dexmedetomidine Compared With Midazolam) Study Group: Dexmedetomidine vs midazolam for sedation of critically ill patients: A randomized trial. JAMA 2009; 301:489 499 www.icudelirium.org

Clarify the reason for sedation and severity of the problem: Pain Negative Effects: Agitation/Anxiety Delirium Sleep Deprivation Metabolic Acidosis ETOH or Drug Withdrawal Depression Need Criteria: Violent and dangerous to self and/or others Uncorrectable severe hypoxia Dangerous hemodynamic instability Temporarily for some procedures Respiratory Depression Hemodynamic Instability

easier for whom? (Peitz, et al) Effects of deep sedation: It Predisposes to VAP It Accelerates Patient De-conditioning It Prolongs Time on Ventilators It Promotes Skin Breakdown Increased 6-month mortality Shehabi, et al; (2012) Sedation Practice in Intensive Care Evaluation (SPICE) Study Investigators; Early intensive care sedation predicts long-term mortality in ventilated critically ill patients. Am J Respir Crit Care Med

The traditional approach to treat ICU sleep deprivation: Heavily sedate critically ill patients with continuous sedative and opioid infusions Peitz, et al., (2013). Top 10 Myths Regarding Sedation and Delirium in the ICU. CCMjournal. 41(9)

Risk Factors: Mechanical Ventilation Untreated Pain Alarms, noise Continuous nurse care Light during nighttime hours Prior Alcohol use Drug therapy (i.e. benzodiazepines, opiates, etc.)

Seymour C et al, CCM 2012;40 August

Physiologic Effects: Impairs immunologic system May affect pulmonary mechanisms and respiratory muscles Increase in pain sensitivity Increase in cortisol levels Disrupted thermoregulation Fatigue, loss of vigor Neuropsychological Effects Irritability, anxiety Impairs cognitive function (attention, memory, concentration) Prolonged sleep deprivation: Hallucinations, perceptual distortions DELIRIUM Drouot, et al. (2007) Sleep in the intensive Care Unit. Sleep Medicine 12:391-403

Beliefs related to lightning sedation: hemodynamic instability, increased oxygen requirements, increased risk of self-extubation, long-term psychological defects ABC Trial (2008) ) trial (SAT followed by SBT) N=436 shortened mechanical ventilation time by > 3 days Less self-extubations (6 vs. 16) Girard et al (2008) Awakening and Breathing reduced ICU by 3.8 days Controlled trial: Lancet; 371:126 134 reduced hospital LOS 4.3 days reduced mortality risk at 1 year (p=0.01)

PTSD: Girard, et al (2007) Risk factors for post-traumatic stress disorder symptoms following critical illness requiring mechanical ventilation: a prospective cohort study. Critical Care, 11 Mental health condition triggered by exposure to a traumatic and extremely disturbing event Hyperarousability Intrusive recollection of events Avoidance/numbing More likely to occur in females, less likely to occur in older pts Memory of pain-independent predictor of PTSD 14% pts who required Mechanical Ventilation (MV) showed post-traumatic stress (PTSD) symptoms after 6 months Sedatives in MV patients linked to this occurrence Daily interruption (SAT) may facilitate periods of alertness and reduce risk of PTSD (p=0.02)

C Choice of Drug

The Pain, Agitation and Delirium (PAD) clinical practice guidelines of the Society of Critical Care Medicine (2013 PAD SCCM/ACCP Guidelines)

Score Sedation Scale Description +4 Combative Overtly violent, immediate danger to self and/or staff. +3 Very Agitated Pulls or removes tube(s) or catheters; aggressive +2 Agitated Frequent non-purposeful movement, fights ventilator +1 Restless Anxious, apprehensive, but not aggressive 0 Alert and calm -1 Drowsy Awakens to voice with eye opening, eye contact (greater than 10 seconds). -2 Light sedation Briefly awakens with eye contact to voice (less than 10 seconds). -3 Moderate sedation Movement or eye opening to voice (no eye contact). -4 Deep sedation No response to voice, but movement or eye opening to physical stimulation -5 Unarousable No response to voice or physical stimulation.

Nurses completed a sedation assessment 21% of patients were found to be motionless and 32% were found to be minimally or non-arousable, yet only 3% were assessed by nurses as over-sedated and 17% were assessed as inadequately sedated Under sedation occurred 5 times more often than over-sedation Weinert, C. R.; Calvin, D.C., CritCare Med 2007; 35(2)

D Delirium Monitoring and Management

Delirium is defined as a disturbance of consciousness with inattention accompanied by a change in cognition or perceptual disturbance that develops over a short period of time (hours to days) and fluctuates over time [The Diagnostic and Statistical Manual of Mental Disorders (DSM IV)]. www.icudelirium.org Cannot think clearly Trouble paying attention Hard time understanding what is going on around them May see or hear things that are not there. These things seem very real to them

Truman & Ely, Critical Care Nurse AACN, 2003

40-60% of non-ventilated patients 60-80% of mechanically ventilated patients Hypoactive delirium is missed in 75% of cases It is the most common organ dysfunction (CIBI) Most under-recognized form of organ dysfunction- CIBI (Critical Illness-associated Brain Injury) Occurs in > half ICU days Spronk P, ICM 2009 Vasilevskis E, Chest 2010 Schweickert W, Lancet 2009 Devlin J, CCM 2010 Pisani M, CCM 2010 Girard T, CCM 2010 Shehabi Y, CCM 2010 Vasilevskis E, CCM 2010

Predicts 3-fold increase death at 6 months 10% increase of risk of death for every day a pt is delirious Predicts longer ICU and hospital LOS Higher cost of care Disposition other than home www.ihi.org

THINK T = Toxic Situations (CHF, shock, dehydration, deliriogenic meds, new organ failure) H = Hypoxemia/hypercarbia I = Infection/inflammation, immobility N = Non-pharmacological interventions K = K+ and other electrolyte abnormalities Brummel, et al. (2013) Implementing Delirium Screening in the ICU: Secrets to Success. CCMJournal Vol 41 Dr DRE D = Diseases Mnemonics from ICUDelirium.org (Sepsis, CHF) R = Removal of Drugs (Stop Benzodiazepines, antihistamines, opiods used for sedation) E = Environment Remove restraints Provide orientation items (clocks, calendars) Reduce isolation/noise Restore day/night light patterns Mobility/promote sleep

Myth #1: Delirium is a benign and expected side effect of being in the ICU Myth #2: Delirium assessment and recognition Is consistent and uniform Myth #3: All ICU delirium is similar and can be managed effectively with medication Myth #4: Deep sedation and amnesia derived from sedative administration in ICU patients result in improved psychological outcomes, especially PTSD Peitz, et al., (2013). Top 10 Myths Regarding Sedation and Delirium in the ICU. CCMjournal. 41(9)

In 275 mechanically ventilated patients, with similar baseline characteristics, delirium was found to be an independent predictor of higher 6- month mortality. Ely, E.W., JAMA. 291(14): 1753-1762, 2004.

Cognitive Impairment: A mental health condition characterized by: Impaired thinking Impaired judgment Memory loss Delirium-independent predictor of long-term cognitive impairment Mild, moderate or severe cognitive impairment 80% of survivors of ICU patients who required mechanical ventilation had long term cognitive impairment, compared to < 15% in non-icu patients Cognitive impairment was seen up to 12 months post discharge Girard, et al. (2010) Delirium as a predictor of ling term Cognitive Impairment in survivors of critical illness. CCM

Depression: Mental health condition characterized by symptoms such as feelings of sadness and disinterest as well as physical symptoms such as lethargy and fatigue. As many as 50% of patients may suffer depression after an ICU stay. Acquired dementia-like long-term disability Girard, et al. (2010) Delirium as a predictor of ling term Cognitive Impairment in survivors of critical illness. CCM

821 patients enrolled in the cohort study: 6% had Cognitive Impairment at baseline 74% developed delirium during their hospital stay. At 3 months 40% had scores similar to patients with moderate TBI 26 % had scores similar to patient with mild Alzheimer s disease At 12 months 34% had scores for patients with moderate TBI 24 % had scores for patient with mild Alzhemier s disease Pandharipande et al., (2013). Long term cognitive impairment after critical Illness. New Engl. J Med, 369:1306-1316

The CAM-ICU method showed: Patients are 10.5 times more likely to have delirium before daily interruption of sedation versus after (P, 0.001). Rapidly reversible, sedation-related delirium showed fewer ventilator (P, 0.001), ICU (P = 0.001), and hospital days (P, 0.001) than persistent delirium Coordinating delirium assessments with daily sedative interruption will improve ability to prognosticate ICU delirium outcomes Patel, et al., (2014) Am J of Resp & Crit Care Med Vol 189 No 6

Undertreated pain and inadequate analgesia is a risk factors for delirium in frail older adults. Appropriate pain management: agitation and delirium Promotes ambulation and mobility Morrison, et al., (2003) Relationship between pain and opiod analgesics on the development of delirium following hip fracture. J of Gerontology, (58) 1 Management of pain using evidence-based practices (PAD Guidelines) Arbour & Gelinas (2011) Setting goals for pain management when using a behavioral scale: Example with the critical care observation tool. CCN. 31:66-68 Barr, et al. (2013) Clinical practice guidelines for the management of pain, agitation and delirium in the adult patients in the Intensive Care Unit. SCCM, 40 (1) p 263-306

Non-Pharmacological Strategies: Address Pain Issues Reorient patient date/time/place/reason hospitalization Update the whiteboards with caregiver names Discuss current events Provide hearing aids/eye glasses Promote Sleep Noise reduction strategies Normal day-night variation in illumination Minimize interruptions in sleep Promote comfort & relaxation (e.g. back care, oral care, massage, etc)

Mobility and daily sedation interruption 59% of patients who received mobility session during their ICU stay, were functioning independently at time of discharge. Schweickert et al. (2009) Early physical and occupational therapy in mechanically ventilated, critically ill patients: A randomized controlled trials. Lancet.

23 days HLOS #3: Day #1 # 1-7 #8 # 9 # 10 # 17 # 22 # 23 Vfib Arrest Code Cool Off Sedatives /Analgesics PT VDRF/Bronc hitis/ Extubated Day#7 Afib OT/ ST Cath Lab/2 Vessel CAD Sx CABGx2 Sx AICD D/C Home

The 2013 PAD Guidelines recommends routine monitoring of delirium (grade 1B Recommendation) If a validated tool for screening delirium is not used, an average of 75% of patients with delirium will be missed Barr, et al. (2013) Clinical practice guidelines for the management of pain, agitation & delirium in the adult patients in the Intensive Care Unit. SCCM, 40 (1) p 263-306 Inouye SK Arch Intern Med. 2001;161:2467-2473. Devlin JW Crit Care Med. 2007;35:2721-2724. Spronk PE Intensive Care Med. 2009;35:1276-1280. van Eijk MM Crit Care Med. 2009;37:1881-1885.

www.icudelirium.org

www.icudelirium.org

E Early Exercise And Mobility

1. Dangling 2. Standing at bedside 3. Transfer to chair (active), includes standing without marching in place 4. Ambulation (marching in place, walking in room or hall) *All may be done with assistance.

M = Myocardial stability with no ischemia in last 24 hrs O = Oxygenation (FiO2 60%, PEEP 10) V = Vasopressors with no increase for at least 2 hrs E = Engages in voice (responds to verbal stimuli) www.icudelirium.org

F Family Communication and Involvement

family-based interventions to comfort confused patients predate modern medicine volunteer specialists who know and understand the patient, families are often motivated to help prevent and resolve delirium. Govig, 2014 N Engl Med 370:16 Family Involvement Benefits: Early mobility Rukstele et al (2013) Making Strides in preventing ICU-acquired weakness: Involving family in early progressive mobility. Critical Care Nursing; 36 (1) Preventing or reducing incidence of delirium Rosenbloom-Blurton et al (2010) Feasibility of family participation in a delirium prevention program for the older hospitalized adult. J Gerontol Nursing; 36 (9)

Progress is impossible without change, and those who cannot change their minds cannot change anything. George Bernard Shaw

Culture Behaviors and beliefs The total of the inherited ideas, beliefs, values, and knowledge Change To change one's opinion; to change the course of history. To exchange for something else www.dictionary.reference.com

Educate staff Use a multifaceted approach to train staff Provide follow up training journal clubs, annual competencies Be persistent and consistent-interdisciplinary rounds Identify possible barriers to change and develop strategies to deal with these barriers Denial Rationalization Blame Uniqueness Unwillingness Lack of skills Listen with empathy-acknowledging you have heard others and that you care. Expect Resistance Lack of knowledge, fear of unknown, ego Use positive strategies to deal with it (i.e.: refocus, state the evidence over and over) Share the wins with the team (showcase the outcomes)!!

Daily Multidisciplinary Rounds Roles of the multidisciplinary team members Physician Nurse leader Educator/CNS/CS Pharmacist Physical/Occupational/Speech Therapist Respiratory Therapist