Director of Adult Critical Care Services MOH ABCDEF Bundles in ICU ABCDEF bundle NASAM Instead of waiting for patients to get better helps ICU patients get better FASTER ABCDEF Bundle ID: 1047287
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1. Zohair Al Aseri FRCPC, EM & CCMDirector of Adult Critical Care Services MOHABCDEF Bundles in ICU
2. ABCDEF bundle: NASAM
3. Instead of waiting for patients to get better helps ICU patients get better FASTER. ABCDEF Bundle
4. NASAM
5. Factors related to Hospitalization-Associated disabilityData from Covinsky KE, Pierluissi E, Johnston CB. Hospitalization-associated disability: "She was probably able to ambulate, but I'm not sure". JAMA. 2011 Oct 26;306(16):1782–93. doi: 10.1001/jama.2011.1556.
6. The most common preventable ICU harms:DeliriumAcquired weaknessDevice-related infectionsDVTPressure ulcers1/5 ICU patients are harmed by adverse events ½ events are preventable. Improving Value, Quality, and Safety in Your ICU with the ICU Liberation Campaign
7. NASAM
8. A: Assess, Prevent, and Manage PainPain in ICU patients Up to 50%Common ICU procedures induce a significant painThree most painful procedures:Chest tube removalWound drain removalArterial line insertion
9. Assessment of pain 1st step before administering pain relief.Pain and delirium interrelatedness. Treating pain is important in the prevention and/or management of deliriumOnly in 35% of the time before ICU procedures!! need improvementA: Assess, Prevent, and Manage Pain
10. Assessment of pain ScaleNumerical rating scale (NRS) Gold standard: Patient's self-report 1–10A: Assess, Prevent, and Manage Pain
11. A: Assess, Prevent, and Manage PainFor non-self reporting patient, use observable behavioral and physiological indicators Behavioral Pain Scale (BPS) Critical-Care Pain Observation Tool (CPOT) Valid & Reliable.Provide selection of pain meds.Evaluate pain meds effectiveness.
12. A: Assess, Prevent, and Manage PainBPS Composed of 3 subscales: Facial expressionMovement of the upper limbsCompliance with mechanical Ventilation 1 (no response) to 4 (full response). 5 or higher is considered to reflect unacceptable pain.
13. A: Assess, Prevent, and Manage PainCPOT 4 components: facial expressionbody movementsmuscle tensioncompliance with the ventilator for intubated patients or vocalization for extubated patients. 0 to 2 with a possible total score ranging from 0 to 8A CPOT ≥ 3 is indicative of significant pain.
14. Pain medications for:Significant pain NRS >4BPS >5CPOT >3 Prior to painful invasive proceduresA: Assess, Prevent, and Manage Pain
15. Parenteral opioids First-line for treating non-neuropathic pain. A: Assess, Prevent, and Manage PainMay induce tolerance over timeNeed for escalating doses to achieve the same analgesic effect.
16. For neuropathic pain GabapentinCarbamazepineOpioidsAdjunctive medications to reduce opioid and its side effects:Non-opioid analgesics: AcetaminophenNSAIDKetamineA: Assess, Prevent, and Manage Pain
17. Use of regional analgesia Ie, epidural analgesiasurgical patientstraumatic rib fractures.Non-pharmacological methods Effective and safeinjury stabilizationpatient repositioninguse of heat/coldA: Assess, Prevent, and Manage Pain
18. Pain, agitation, and delirium (PAD)
19. Both Spontaneous Awakening Trials (SAT) and Spontaneous Breathing Trials (SBT)Pts. receiving SATs with SBTs were less likely to die than pts receiving only SBTs (p=0·01). For every 7 pts treated with the intervention, one life was saved (number needed to treat was 7.4,).
20. Spontaneous Awakening Trials (SAT) Spontaneous Breathing Trials (SBT)Deep Sedation Risk factor for ICU MorbidityStopping narcotics (as pain is controlled) & sedatives every dayDailY SATs If needed, restarting either at ½ previous dose & titratingLight sedationearlier extubationLOWER mechanical ventilation and ICU length Core of NASAM
21. C: Choice of analgesia and sedationGoal-directed delivery of psychoactive medications: By using sedation scalesPAD guidelines recommend:Richmond Agitation-Sedation Scale (RASS)Riker Sedation-Agitation Scale (SAS).
22. RAS OR SASDeep Sedation Risk factor for ICU MorbiditySedation scaleLight sedationSedation protocolsLOWER mechanical ventilation and ICU length Core of NASAMRASSSASearlier extubationnon-benzodiazepine sedative benzodiazepine-based sedative
23. D: Delirium: Assess, Prevent, and ManageDelirium Disturbance in attention and awarenessDevelops over a short period of time, hours to daysFluctuates over time.Over 80% of pts developed delirium during hospital stayOnset between 2nd and the 3rd day.
24. D: Delirium: Assess, Prevent, and ManageTow most frequently used tools to diagnose delirium in ICU:Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) Intensive Care Delirium Screening Checklist (ICDSC)
25. E: Early mobilityThe only intervention resulting in a decrease in days of delirium.ICU-acquired weakness ranges from 25 to 100%.ICU patients can lose up to 25% peripheral muscle weakness within Four days when mechanically ventilated
26. D: Delirium: Assess, Prevent, and ManageReduce incidence and duration of ICU deliriumImprove functional outcomesDecrease mortalityMore days off ventPromoting sleep hygiene to prevent sleep disruptionEarly mobilization & SAT+=
27. Will not improve long-term functioning when started after 4th dayEarly in the ICU better than lateRehabilitation should begin in the ICU and continue to recovery at home. Close collaboration and coordination with all needed services.E: Early mobility
28. F: Family engagementPatients’ preferences can be identifiedPhysicians can have appropriate input Anxiety of families can be lessened* Family decision makers is active in decision-making* Ethics & palliative consultation* Routine family conference InterventionBenefitsReduce ICU length for terminal cases
29. A,B,C,D,E&F to all ICU patients at the right time:It is an interdependent, complex, and dynamic process.Requires coordination and collaboration of providers across disciplines.
30. Increasing patient mobilityReducing prevalence of deliriumReducing duration of mechanical ventilation
31. NASAM
32. Bundle elements are addressed for every ICU patient, every dayWork flows are standardized. ABCDEF & EHRTranslate evidence into clinical practiceReduce ICU clinician practice variationExtraction of bundle compliance, performance, and outcome reports from the EHRIncorporate bundle elements into HER
33. To look at the association between complete and proportional ABCDEF bundle and 3 sets of outcomes: Patient-related (mortality, ICU and hospital discharge)Symptom-related (mechanical ventilation, coma, delirium, pain, restraint use)System-related (ICU readmission, discharge destination)Pun, Brenda T. Critical Care Medicine: January 2019 - Volume 47 - Issue 1Caring for Critically Ill Patients with the ABCDEF Bundle: Results of the ICU Liberation Collaborative in Over 15,000 Adults.Prospective, multicenter, cohort68 ICUs over 20-month period 15,226 adults
34. Results: Complete ABCDEF bundle performance was associated with lower likelihood of seven outcomes: Pun, Brenda T. Critical Care Medicine: January 2019 - Volume 47 - Issue 1Caring for Critically Ill Patients with the ABCDEF Bundle: Results of the ICU Liberation Collaborative in Over 15,000 Adults.Hospital death within 7 days Next-day mechanical ventilation ComaDelirium Physical restraint use ICU readmission Discharge to a facility other than homeA consistent relationship between higher bundle performance & improvements in each clinical outcomes (all p < 0.002).
35. Caring for Critically Ill Patients with the ABCDEF Bundle: Results of the ICU Liberation Collaborative in Over 15,000 Adults Pun, Brenda T. Critical Care Medicine: January 2019 - Volume 47 - Issue 1 - p 3-14 doi: 10.1097/CCM.0000000000003482Society of Critical Care Medicine. Critical care statistics. Mt. Prospect, IL: Society of Critical Care Medicine. https://www.sccm.org/Communications/Critical-Care-Statistics. Accessed July 9, 2018.Rothschild JM, Landrigan CP, Cronin JW, et al. The Critical Care Safety Study: The incidence and nature of adverse events and serious medical errors in intensive care. Crit Care Med. 2005 Aug;33(8):1694-1700.Kaushal R, Bates DW, Franz C, Soukup JR, Rothschild JM. Cost of adverse events in intensive care units. Crit Care Med. 2007 Nov;35(11):2479-2483.Barr J, Fraser GL, Puntillo K, et al; American College of Critical Care Medicine. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013 Jan;41(1):263-306.Needham DM, Davidson J, Cohen H, et al. Improving long-term outcomes after discharge from intensive care unit: report from a stakeholders’ conference. Crit Care Med. 2012 Feb; 40(2):502-509.Marra A, Pandaripande PP, Girard TD, et al. Cooccurrence of post-intensive care syndrome problems among 406 survivors of critical illness. Crit Care Med. 2018 May 21. [Epub ahead of print].Elliott D, Davidson JE, Harvey MA, et al. Crit Care Med. 2014 Dec; 42(12):2518-2526.Harvey MA, Davidson JE. Postintensive care syndrome: right care, right now . . . and later. Crit Care Med. 2016 Feb;44(2):381-385.Davidson JE, Harvey MA. Patient and family post-intensive care syndrome. AACN Adv Crit Care. 2016 April-June;27(2):184-186.ICU Liberation. ABCDEF bundle. http://www.iculiberation.org/Bundles/Pages/default.aspx. Mt. Prospect, IL: Society of Critical Care Medicine. Accessed June 12, 2018.Balas MC, Vasilevskis EE, Olsen KM, et al. Effectiveness and safety of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle. Crit Care Med. 2014 May;42(5):1024-1036.Barnes-Daly MA, Phillips G, Ely EW. Improving hospital survival and reducing brain dysfunction at seven California community hospitals: implementing PAD guidelines via the ABCDEF bundle in 6,064 patients. Crit Care Med. 2017 Feb;45(2):171-178.Donovan AL, Aldrich JM, Gross AK, et al; University of California San Francisco Critical Care Innovations Group. Interprofessional care and teamwork in the ICU. Crit Care Med 2018 Jun;46(6):980-990.Balas MC, Burke WJ, Gannon D, et al. Implementing the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle into everyday care: opportunities, challenges, and lessons learned for implementing the ICU pain, agitation, and delirium guidelines. Crit Care Med 2013 Sep;41(9 Suppl 1):S116-S127.Costa DK, Barg FK, Asch DA, Kahn JM. Facilitators of an interprofessional approach to care in medical and mixed medical/surgical ICUs” a multicenter qualitative study. Res Nurs Health. 2014 Aug;37(4):326-335.Harvard Business Review. Want to be a more supportive leader? Here’s how. June 25, 2018. Boston, MA: Harvard Business School Publishing Corporation. https://www.physicianleaders.org/news/want-more-supportive-leader-heres-how. Accessed June 27, 2018.Kambil A. Four types of executive sponsorship to catalyze change. October 11, 2017. New York, NY: Deloitte Insights. https://www2.deloitte.com/insights/us/en/focus/executive-transitions/four-types-of-executive-sponsorship-to-catalyze-change.html. Accessed June 27, 2018.Institute for Healthcare Improvement. The IHI Triple Aim. Boston, MA: Institute for Healthcare Improvement; 2018. http://www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx. Accessed July 24, 2018references
36. Bundles for Critical Care PateintsSBTNo BenzoPain scale & TTTDelirium Assessment Family participationSleep hygieneEarly mobilizationSATNASAM
37. Q&AThank youNASAM