Implementing a set of practices to encourage patients mobility and decrease sedation effectively reduces delirium and the need for a ventilator, according to a study.
By increasing patients mobility during hospitalization, the practice bundle also decreases weakness, according to the study, which was funded by the Robert Wood Johnson Foundation Interdisciplinary Nursing Quality Research Initiative and published earlier this year on the website of the journal Critical Care Medicine.
Researchers 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, associate professor at The Ohio State University, and William Burke, MD, professor of psychiatry and vice chairman 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, a step-down unit and an oncology/special care unit in a medical center. They compared the 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 in the control group). Fewer of those patients experienced delirium (48.7% compared with 62.3%), 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 stays, and lower hospital mortality (11.3% compared with 19.9%).
Even though the team didnt fully and consistently adhere to the bundle protocol, we saw significant differences in the two groups of patients, Balas said in a news release. 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 reduce that patients weakness, reduce 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, according to the news release. 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 patients 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, Burke said in the news release. 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.
Study abstract: http://journals.lww.com/ccmjournal/Abstract/publishahead/Effectiveness_and_Safety_of_the_Awakening_and.97609.aspx