Effectiveness and safety of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle

Abstract

Objective: The debilitating and persistent effects of ICU-acquired delirium and weakness warrant testing of prevention strategies. The purpose of this study was to evaluate the effectiveness and safety of implementing the Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility bundle into everyday practice.

Design: Eighteen-month, prospective, cohort, before-after study conducted between November 2010 and May 2012.

Setting: Five adult ICUs, one step-down unit, and one oncology/hematology special care unit located in a 624-bed tertiary medical center.

Patients: Two hundred ninety-six patients (146 prebundle and 150 postbundle implementation), who are 19 years old or older, managed by the institutions' medical or surgical critical care service.

Interventions: Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility bundle.

Measurements and main results: For mechanically ventilated patients (n = 187), we examined the association between bundle implementation and ventilator-free days. For all patients, we used regression models to quantify the relationship between Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility bundle implementation and the prevalence/duration of delirium and coma, early mobilization, mortality, time to discharge, and change in residence. Safety outcomes and bundle adherence were monitored. Patients in the postimplementation period spent three more days breathing without mechanical assistance than did those in the preimplementation period (median [interquartile range], 24 [7-26] vs 21 [0-25]; p = 0.04). After adjusting for age, sex, severity of illness, comorbidity, and mechanical ventilation status, patients managed with the Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility bundle experienced a near halving of the odds of delirium (odds ratio, 0.55; 95% CI, 0.33-0.93; p = 0.03) and increased odds of mobilizing out of bed at least once during an ICU stay (odds ratio, 2.11; 95% CI, 1.29-3.45; p = 0.003). No significant differences were noted in self-extubation or reintubation rates.

Conclusions: Critically ill patients managed with the Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility bundle spent three more days breathing without assistance, experienced less delirium, and were more likely to be mobilized during their ICU stay than patients treated with usual care.

Figure 1. ABCDE Bundle Policy

RN = Registered Nurse, RT = Respiratory Therapist, PT = Physical Therapist, SAT = Spontaneous Awakening Trial; SBT = Spontaneous Breathing Trial; RASS = Richmond Agitation-Sedation Scale; CAM-ICU = Confusion Assessment Method for the Intensive Care Unit. ^aContinuous sedative medications maintained at previous rate if SAT safety screen failure. Mechanical ventilation continued, and continuous sedative medications restarted at half the previous dose only if needed due to SBT safety screen failure. ^bContinuous sedative infusions stopped, and sedative boluses held. Bolus doses of opioid medications allowed for pain. Continuous opioid infusions maintained only if needed for active pain. ^cContinuous sedative medications restarted at half the previous dose, and then titrated to sedation target if SAT failed. Interdisciplinary team determines possible causes of SAT/SBT failure during rounds. Mechanical ventilation restarted at previous settings, and continuous sedative medications restarted at half the previous dose only if needed if SBT failed. ^dSAT pass if the patient is able to open his/her eyes to verbal stimulation without failure criteria (regardless of trial length) or does not display any of the failure criteria after four hours of shutting off sedation. ^eEach day on interdisciplinary rounds, the RN will inform the team of the patient’s target RASS score, actual RASS score, CAM-ICU status, and sedative and analgesic medications the patients is receiving. If delirium is detected, team will discuss possible causes, eliminate risk factors, and employ non-pharmacologic management strategies. ^fEach eligible patient is encouraged to be mobile at least once a day, with the specific level of activity geared to his or her readiness. Patients progress through a three-step process, embarking on the highest level of physical activity they can tolerate. Progress includes sitting on edge of bed, standing at bedside and sitting in chair, and walking a short distance. Use of the protocol ends when the patient is discharged from the ICU.

Figure 2. PATIENT FLOW DIAGRAM

LAR = Legally Authorized Representative.