How to Improve ICU Patient Outcomes with the ABCDEF Bundle

Once we take into consideration the intensive care unit, most of us would assume it’s a spot that gives the absolute best remedy for sufferers, and is at all times on the reducing fringe of science, drugs and expertise.

However whereas this can be true in lots of elements, in terms of issues like sedation, early mobility, and administration of delirium within the ICU, sadly, most ICUs are nonetheless utilizing woefully outdated practices.

Through the years, I’ve seen time and time once more how these outmoded protocols can have a fully devastating impact on affected person outcomes.

One significantly egregious instance of this concerned a lady named Susanne.

That is her story.

How Susanne Grew to become a Sufferer of the ICU Meeting Line

Susanne was a wholesome 49-year-old girl who developed Ludwig’s angina. She was admitted to the ICU for sepsis and polymicrobial cellulitis airway compromise attributable to vital submandibular swelling.

She was intubated and placed on mechanical air flow to guard her airway.

Previous to intubation, the dangers of extended sedation and immobility weren’t disclosed to Susanne and her household, and he or she was not given the choice to be awake and cell.

As a result of prevailing ICU tradition of robotically sedating each affected person on mechanical air flow, Susanne was deeply sedated and motionless for 18 days, regardless of the dearth of a transparent indication of the necessity for extended deep sedation.

It is very important perceive that accumulating proof exhibits there are just a few instances through which steady deep sedation is important for sufferers on mechanical air flow.

These exceptions embrace issues like intracranial hypertension, extreme respiratory failure, refractory standing epilepticus, and prevention of consciousness in sufferers handled with neuromuscular blocking brokers.

For sure, Susanne didn’t require deep sedation, and there’s proof to indicate she would have been a main candidate for remaining awake whereas on the ventilator.

Susanne stories struggling deeply traumatizing delirium that included vivid and graphic delusions that felt extra actual to her than the fact she now lives.

It’s unclear how lengthy she wanted the endotracheal tube for the safety of her airway, however lengthy earlier than she was liberated from sedation and extubated, she was given sedation holidays in makes an attempt to do respiration trials.

Nevertheless, when sedation was decreased, she turned bodily lively and expressed the phobia and agitation she was experiencing from her delirium. This can be a frequent prevalence throughout sedation holidays.

At this level, Susanne remembers listening to clinicians at her bedside saying, “Nicely, she’s too loopy. She’s not prepared to come back off of this. We’ll strive once more in a number of days.”

It’s anybody’s guess what number of extra days of mechanical air flow, deep sedation, and delirium Susanne was subjected to due to her response to what she had skilled.

Her husband lastly satisfied the ICU staff to take sedation off, enable Susanne to get up, and get her off the ventilator. With out his persistence, who is aware of how for much longer she would have needed to endure this struggling.

Remarkably, her lungs have been wholesome, and the swelling in her airway had doubtless decreased effectively earlier than 18 days had elapsed, however attributable to her ICU staff’s outdated practices, she remained sedated as a result of she was intubated and intubated as a result of she was sedated.

When she was admitted to the ICU, Susanne weighed 130 kilos, however throughout these 18 days of immobility and muscular atrophy, she misplaced 35 kilos – primarily of lean muscle.

She stories that the primary time she stood on her ft once more after being sedated was like stepping on glass due to the neuropathy she had developed.

Her journey to rebuild muscle, regain the load, and return to her baseline psychological, cognitive, and bodily capability has been fairly the battle, and Susanne needs she had been allowed to stay awake, current, and cell throughout her ICU keep.

Sadly, Susanne fell sufferer to the ICU meeting line of computerized deep sedation and immobility for each affected person on mechanical air flow.

She suffered ICU delirium, ICU-acquired weak spot, extended time on the ventilator, and potential long-term deficits due to the selection to sedate her for 18 days.

Lengthy after her ICU discharge, Susanne continues to be haunted by the stress, terror, and panic skilled whereas beneath sedation.

If you wish to know extra about her story, you’ll be able to take heed to Episode 92 of my Strolling Dwelling From The ICU podcast.

How the ABCDEF Bundle Can Enhance ICU Affected person Outcomes for Folks Like Susanne

The choice to deeply sedate Susanne is typical of ICU tradition, and was doubtless recurring, however there was actually no want for it.

If this ICU staff was following evidence-based practices, they’d have utilized the ABCDEF Bundle to assist Susanne keep awake, freed from delirium, and cell throughout her time on mechanical air flow.

The ABCDEF Bundle offers a set of evidence-based practices for easy methods to enhance ICU affected person outcomes for individuals who could require sedation within the ICU.

It encourages train and early mobility within the ICU, household engagement and empowerment, the evaluation, prevention, and administration of each ache and delirium, and in addition recommends conducting each Spontaneous Awakening Trials (SATs) and Spontaneous Respiration Trials (SBTs), whereas permitting sufferers to decide on whether or not they wish to obtain analgesia and sedation.

The failure to use the ABCDEF bundle in Susanne’s care elevated her danger of:

● Dying

● Delirium

● Submit-ICU PTSD

● Submit-ICU cognitive impairments

● Submit-ICU syndrome

● ICU-acquired weak spot

● Extended time on the ventilator

● Hospital-acquired infections

● Hospital-acquired stress accidents

● Intensive rehabilitation

● Longer time within the ICU and hospital

● Elevated danger of hospital and ICU readmission

Susanne’s story offers a transparent instance of the outcomes from quite a few research, which present that deep sedation sometimes leads to extra time on the ventilator.

It’s additionally necessary to say that correct sedation practices and early mobility within the ICU have been proven to enhance ICU affected person outcomes, and certain would have prevented delirium and considerably decreased Susanne’s time on the ventilator, amongst different outcomes.

If her ICU staff had been following evidence-based practices, they’d have identified that:

1. Extended sedation prevents sleep, which causes delirium.
2. Delirium is commonly very traumatic and causes agitation and panic, as sufferers could expertise violent, graphic, and terrifying realities, that are far worse than the fact of being within the ICU.
3. Susanne’s psychomotor exercise was doubtless occurring as a result of truth she was affected by hyperactive delirium, and never due to the discomfort brought on by her endotracheal tube.
4. Delirium is a life-threatening situation and a medical emergency.
5. The one remedy for delirium is to STOP drugs that trigger delirium, whereas permitting for household involvement, mobility, and REAL sleep.
6. Resuming sedation at that second does NOT make sufferers “extra comfy.” Turning sedation again on will trigger, exacerbate, and lengthen delirium, growing the chance of affected by the repercussions of sedation and immobility. Sending sufferers again into the depths of delirium isn’t humane and isn’t an evidence-based observe.

Lengthy story quick, the ABCDEF bundle might have prevented a lot of this pointless struggling, and alleviated the prices of money and time for each Susanne and her ICU care staff.

If you wish to know extra about how I will help you advocate for evidence-based practices in your ICU, or the ICU the place your member of the family has been admitted, please don’t hesitate to contact me.

Kali Dayton