Helping Critically Ill Patients on Mechanical Ventilators Stay Alert, Calm and Free from Delirium

Patients on ventilators in hospital intensive care units (ICU) are at high risk for delirium and weakness, which can not only interfere with their recovery, but can also impair their physical and psychological health after they leave the hospital. The annual cost of caring for delirious patients on ventilators is estimated at $6.5 to $20.4 billion.

A new effort to improve care for ICU patients, funded by the Robert Wood Johnson Foundation Interdisciplinary Nursing Quality Research Initiative (INQRI) and published in a recent issue of Critical Care Nurse, reveals that a bundle of practices, employed by a nurse-led interprofessional team of health care providers, could help ICU patients avoid delirium and weakness so they heal sooner and are healthier after leaving the hospital.

The implementation of these practices was conducted by an interprofessional team led by Michele Balas, RN, PhD, APRN-NP, CCRN, assistant professor at the University of Nebraska Medical Center, College of Nursing, and William Burke, MD, professor of psychiatry and vice-chair for research at the University of Nebraska Medical Center. They examined a “bundle” of evidence-based practices called the Awakening, and Breathing Coordination, Delirium Monitoring and Management, and Early Mobility bundle (ABCDE bundle).

“Delirium and weakness can have profound negative effects on patients’ recovery and on their lives after they are discharged from the hospital,” said Burke. “There are instances of patients who suffered delirium in the ICU experiencing post-traumatic stress disorder after going home. As health care providers, we must do everything we can do ensure our patients’ rapid return to health and help them avoid any trauma. This series of practices does that.”

The ABCDE bundle uses the best available evidence on delirium, immobility, sedation and analgesia, and ventilator management in the ICU. 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 patient’s 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.

The article describes how to implement the bundle, and the roles of each member of the team providing care to patients in the ICU, with particular attention to central role of the nurse.

“The ABCDE bundle is complex, but it holds great potential for decreasing the time critically-ill patients need to spend on ventilators and in the ICU, and decreasing their recovery time after they leave the hospital,” said Balas. “Because they are the health care providers who interact most frequently and for the longest periods of time with patients, nurses are the linchpin in this intervention. They are responsible for the initial assessment of patients, for some of the procedures and they are the communications link for the health care team.”