PADGuidelines:ToolsforImplementation

PADGuidelines(Abstract)

Implementingthe2013PADGuidelines:TopTenPointstoConsider(Abstract)

PADGuidelineImplementation:GapAnalysisSurvey

AssessmentTools

Pain

BehavioralPainScale(BPS)

CriticalCarePainObservationTool(CPOT)

Agitation/Sedation

RichmondAgitationSedationScale(RASS)

SedationAgitationScale(SAS)

Delirium

ConfusionAssessmentMethodfortheICU(CAMICU)

IntensiveCareDeliriumScreeningChecklist(ICDSC)

WakeUpandBreatheProtocol

ProgressiveMobilityProtocol

Exercise/MobilitySafetyScreenandTherapy

PointstoConsiderWhenImplementingtheABCDEBundle

ClinicalPracticeGuidelinesfortheManagementofPain,Agitation,
andDeliriuminAdultPatientsintheIntensiveCareUnit
JulianaBarr,GillesL.Fraser,KathleenPuntillo,E.WesleyEly,ClineGlinas,JosephF.Dasta,JudyE.Davidson,
JohnW.Devlin,JohnP.Kress,AaronM.Joffe,DouglasB.Coursin,DanielL.Herr,AveryTung,BryceR.H.Robinson,
DorrieK.Fontaine,MichaelA.Ramsay,RichardR.Riker,CurtisN.Sessler,BrendaPun,YoannaSkrobik,RomanJaeschke
CritCareMed.2013;41:263306.(CompleteGuidelines)
AmJHealthSystPharm.2013;70:5358.(ExecutiveSummary)

Abstract
Objective:TorevisetheClinicalPracticeGuidelinesfortheSustainedUseofSedativesandAnalgesicsin
theCriticallyIllAdultpublishedinCriticalCareMedicinein2002.
Methods:TheAmericanCollegeofCriticalCareMedicineassembleda20person,multidisciplinary,multi
institutionaltaskforcewithexpertiseinguidelinedevelopment,pain,agitationandsedation,delirium
management,andassociatedoutcomesinadultcriticallyillpatients.Thetaskforce,dividedintofour
subcommittees,collaboratedover6yrinperson,viateleconferences,andviaelectroniccommunication.
Subcommitteeswereresponsiblefordevelopingrelevantclinicalquestions,usingtheGradingof
RecommendationsAssessment,DevelopmentandEvaluationmethod(http://www.gradeworkinggroup.org)
toreview,evaluate,andsummarizetheliterature,andtodevelopclinicalstatements(descriptive)and
recommendations(actionable).WiththehelpofaprofessionallibrarianandRefworksdatabasesoftware,
theydevelopedaWebbasedelectronicdatabaseofover19,000referencesextractedfromeightclinical
searchengines,relatedtopainandanalgesia,agitationandsedation,delirium,andrelatedclinicaloutcomes
inadultICUpatients.Thegroupalsousedpsychometricanalysestoevaluateandcomparepain,
agitation/sedation,anddeliriumassessmenttools.Alltaskforcememberswereallowedtoreviewthe
literaturesupportingeachstatementandrecommendationandprovidedfeedbacktothesubcommittees.
Groupconsensuswasachievedforallstatementsandrecommendationsusingthenominalgrouptechnique
andthemodifiedDelphimethod,withanonymousvotingbyalltaskforcemembersusingESurvey
(http://www.esurvey.com).Allvoting wascompletedinDecember2010.Relevantstudiespublishedafter
thisdateandpriortopublicationoftheseguidelineswerereferencedinthetext.Thequalityofevidencefor
eachstatementandrecommendationwasrankedashigh(A),moderate(B),orlow/verylow(C).The
strengthofrecommendationswasrankedasstrong(1)orweak(2),andeitherinfavorof(+)oragainst()
anintervention.Astrongrecommendation(eitherfororagainst)indicatedthattheinterventionsdesirable
effectseitherclearlyoutweigheditsundesirableeffects(risks,burdens,andcosts)oritdidnot.Forallstrong
recommendations,thephraseWerecommendisusedthroughout.Aweakrecommendation,eitherfor
oragainstanintervention,indicatedthatthetradeoffbetweendesirableandundesirableeffectswasless
clear.Forallweakrecommendations,thephraseWesuggestisusedthroughout.Intheabsenceof
sufficientevidence,orwhengroupconsensuscouldnotbeachieved,norecommendation(0)wasmade.
Consensusbasedonexpertopinionwasnotusedasasubstituteforalackofevidence.Aconsistentmethod
foraddressingpotentialconflictofinterestwasfollowediftaskforcememberswerecoauthorsofrelated
research.Thedevelopmentofthisguidelinewasindependentofanyindustryfunding.
Conclusion:Theseguidelinesprovidearoadmapfordevelopingintegrated,evidencebased,andpatient
centeredprotocolsforpreventingandtreatingpain,agitation,anddeliriumincriticallyillpatients.

Implementingthe2013PADGuidelines:
TopTenPointstoConsider

PunBT,BalasMC,DavidsonJ.
SeminRespirCritCareMed.2013;34:223235.

Abstract:Ithasbeen10yearssincethelastpublicationoftheclinicalpracticeguidelinesfor
pain,agitation/sedation,anddelirium(PAD).Theresultsofnewstudieshavedirected
significantchangesincriticalcarepractice.UsingtheGradesofRecommendation,Assessment,
Development,andEvaluation(GRADE)methodology,theguidelineswererevised,resultingin
32recommendationsand22summarystatements.Thisarticleprovidesguidancetoward
guidelineimplementationstrategiesandoutlines10keypointstoconsider.Comparedwithits
predecessor,the2013PADguidelinesarelessprescriptiveinthattheyrecommendapproaches
topatientcareratherthangivingspecificmedicationrecommendations.Thiswillhelpfocus
careteamsontheprocessandstructureofpatientmanagementandresultinmoreflexibility
whenchoosingspecificmedications.Thisarticleoutlinesapproachestoguideline
implementationthattakeintoaccountthechangesinphilosophysurroundingmedication
selection.Themanuscriptfocusesontheareasanticipatedtogeneratethemostchangesuchas
lightersedationtargets,avoidanceofbenzodiazepines,andearlymobility.Agapanalysisgridis
provided.Thereleaseofanyguidelineshouldpromptreevaluationofcurrentinstitutional
practicestandards.ThismanuscriptusesthePADguidelinesasanexampleofhowtoapproach
theinterprofessionalworkofguidelineimplementation.

TopTenPointsforPADGuidelineImplementation
1. Understandtheprescriptivenatureoftheguidelines
2. Performagapanalysisandprepareanelevatorspeech
3. Focusontheinterprofessionalnatureoftheguidelines
4. Startwithpain,agitation,anddeliriumassessment
5. Provideintense,sustained,interprofessionaleducation
6. Focusonlightsedation
7. Usenonbenzodiazepinesedationstrategies
8. Expectconfusionregardingtheroleofantipsychoticmedications
9. Usenonpharmacologicpain,agitation,anddeliriummanagementstrategies
10. Mobilizepatientsearlyandoften

PADGuidelineImplementation:GapAnalysisSurvey
Never

Overall

RecommendusinganinterdisciplinaryICUteamapproachthatincludes
provider/education,preprintedand/orcomputerizedprotocolsandorderforms,and
qualityICUroundscheckliststofacilitatetheuseofpain,agitation,anddelirium
managementguidelinesorprotocolsinadultICUs(+1B).

Some
times

Statements/Recommendations

Usually

Area

Almost
always

CurrentPractice

Pain

Assessment

Management
Strategy

Drug
Choice

Treatmentof
Pain

PainassessmentshouldberoutinelyperformedinallICUpatients(+1B).
Whichtooltouse?
SelfreportispreferredovertheuseofbehavioralpainscalestoassesspaininICU
patientswhoareabletocommunicate.
TheBPSandCPOTarethemostvalidandreliablebehavioralpainscalesforusein
ICUpatientswhocannotcommunicate(B).

Vitalsignsshouldnotbeusedalonetoassesspain(2C),buttheymaybeusedas
acuetobeginfurtherassessmentofpain(+2C).

Preemptivelytreatchesttuberemovalwithanalgesicsand/ornonpharmacologic
therapy(e.g.,relaxation)(+1C).

Considerpreemptivelytreatingothertypesofproceduralpainwithanalgesic
and/ornonpharmacologictherapy(+2C).

Useopioidsasfirstlinetherapyfortreatmentofnonneuropathicpain(+1C).

Considerusingnonopioidanalgesicsinconjunctionwithopioidstoreduceopioid
administrtaionandopioidrelatedsideeffects(+2C).

Useenteralgabapentinorcarbamazepine,inadditiontointravenousopioids,for
treatmentofneuropathicpain(+1A).

Usethoracicepiduralanesthesia/analgesiaforpostoperativeanalgesiain
abdominalaorticsurgerypatients(+1B).

Considerthoracicepiduralanalgesiabeusedforpatientswithtraumaticrib
fractures(+2B).

Norecommendation(fororagainst):
Usingalumbarepiduraloverparenteralopioidsforpostoperativeanalgesiain
patientsundergoingabdominalaorticaneurysmsurgery,duetoalackofbenefit
ofepiduraloverparenteralopioidsinthispatientpopulation(0,A).
Theuseofthoracicepiduralanalgesiainpatientsundergoingeitherintrathoracic
ornonvascularabdominalsurgicalprocedures,duetoinsufficientandconflicting
evidenceforthismodeofanalgesicdeliveryinthesepatients(0,B).
Forneuraxial/regionalanalgesiaoversystemicanalgesiainmedicalICUpatients,
duetolackofevidenceinthispatientpopulation(0,NoEvidence).

Agitation/Sedation

Assessment

Routinelymonitordepthandqualityofsedation.
Whichtooltouse?
TheRASSandSASarethemostvalidandreliablescalesforassessingqualityand
depthofsedationinICUpatient(B).

Donotuseobjectivemeasuresofbrainfunctionasprimarymethodofmonitoring
depthofsedationinnoncomatose,nonparalyzedpatients(1B).

Suggestusingobjectivemeasuresofbrainfunctiontoadjunctivelymonitor
sedationinpatientsreceivingneuromuscularblockingagents(+2B).

UseEEGmonitoringeithertomonitornonconvulsiveseizureactivityinICU
patientswithknownorsuspectedseizures,ortotitrateelectrosuppressive
medicationtoachieveburstsuppressioninICUpatientswithelevatedintracranial
pressure(+1A).

Management
Strategy

Drug
Choice

Management
Strategy

Drug
Choice

Sleep

Never

Titratesedativemedicationstomaintainalightratherthanadeeplevelof
sedationinadultICUpatients,unlessclinicallycontraindicated(+1B).

Fortitrationuseeitherdailysedationinterruptionorlighttargetlevelofsedation
(+1B).

Suggestusinganalgesiafirstsedationforintubatedandmechanicallyventilated
ICUpatients(+2B).

Suggestusingnonbenzodiazepinesforsedation(eitherpropofolor
dexmedetomidine)ratherthanbenzodiazepines(eithermidazolamorlorazepam)
inmechanicallyventilatedadultICUpatients(+2B).

Delirium
Assessment

Some
times

Statements/Recommendations

Almost
always

Area

Usually

CurrentPractice

DeliriumassessmentshouldberoutinelyperformedinallICUpatients(+1B).
Whichtooltouse?
TheCAMICUandICDSCdeliriummonitoringtoolsarethemostvalidandreliable
scalestoassessdeliriuminICUpatients(A).

MobilizeICUpatientsearlywhenfeasibletoreducetheincidenceanddurationof
delirium,andtoimprovefunctionaloutcomes(+1B).

Norecommendation(fororagainst)
Theuseofapharmacologiconlyoracombinednonpharmacologic+
pharmacologicdeliriumpreventionprotocolinadultICUpatients,asno
compellingdatademonstratethatthisreducestheincidenceordurationof
deliriuminthesepatients(0,C).

AvoidusingrivastigminetoreducethedurationofdeliriuminICUpatients(1B).

Forprevention:
Wedonotsuggestthateitherhaloperidoloratypicalantipsychoticsbe
administeredtopreventdeliriuminadultICUpatients(2C).
Weprovidenorecommendationfortheuseofdexmedetomidinetoprevent
deliriuminadultICUpatients,asthereisnocompellingevidenceregardingits
effectivenessinthesepatients(0,C).

Thereisnopublishedevidencethattreatmentwithhaloperidolreducesthe
durationofdeliriuminadultICUpatients(NoEvidence).

AvoidusingrivastigminetoreducethedurationofdeliriuminICUpatients(1B).

Suggestavoidingtheuseofantipsychoticsinpatientswhoareatriskfortorsades
depointes(2B).

SuggestusingdexmedetomidineinsteadofbenzodiazepinesinICUpatientswith
deliriumunrelatedtoalcohol/benzodiazepinewithdrawal(+2B).

Suggestagainstusingeitherhaloperidoloratypicalantipsychoticstoprevent
deliriuminICUpatients(2C).

WerecommendpromotingsleepinadultICUpatientsbyoptimizingpatients
environments,usingstrategiestocontrollightandnoise,clusteringpatientcare
activities,anddecreasingstimuliatnighttoprotectpatientssleepcycles(+1C).
Norecommendation(fororagainst):Weprovidenorecommendationforusing
specificmodesofmechanicalventilationtopromotesleepinmechanically
ventilatedadultICUpatients,asinsufficientevidenceexistsfortheefficacyof
theseinterventions(0,NoEvidence).

Abbreviations:ICU:IntensiveCareUnit;BPS:BehavioralpainScale;CPOT:CriticalCarePainObservationTool;RASS:RichmondAgitationSedation
Scale;SAS:SedationAgitationScale;EEG:electroencephalography;CAMICU:ConfusionAssessmentMethodfortheICU;ICDSC:IntensiveCare
DeliriumScreeningChecklist.

AdaptedfromPunB,BalasMC,DavidsonJ.Implementingthe2013PADguidelines:toptenpointstoconsider.SeminRespirCritCareMed.
2013;34:223235.

BehavioralPainScale(BPS)
Item

Facialexpression

Upperlimbs

Compliancewith
mechanicalventilation

Description
Relaxed

Partiallytightened(e.g.,browlowering)

Fullytightened(e.g.,eyelidclosing)

Grimacing

Nomovement

Partiallybent

Fullybentwithfingerflexion

Permanentlyretracted

Toleratingmovement

Coughingbuttoleratingventilationmostofthetime

Fightingventilator

Unabletocontrolventilation

PayenJF,etal.CritCareMed.2001;29:22582263.

Score

CriticalCarePainObservationTool(CPOT)

GlinasC,etal.AmJCritCare2006;15:420427.
GlinasC,etal.ClinJPain2007;23:497505.

RichmondAgitationSedationScale(RASS)
Score

State

Description

+4

Combative

+3

Veryagitated

+2

Agitated

Frequentnonpurposefulmovement,fightsventilator

+1

Restless

Anxious,butmovementsnotaggressiveorvigorous

Alertandcalm

Drowsy

Lightsedation

Brieflyawakenswitheyecontacttovoice(<10seconds)

Moderatesedation

Movementoreyeopeningtovoice(butnoeyecontact)

Deepsedation

Noresponsetovoice,butmovementoreyeopeningto
physicalstimulation

Unarousable

Overtlycombative,violent,immediatedangertostaff
Pullsorremovestube(s)orcatheter(s);aggressive

Notfullyalert,buthassustainedawakening(eye
opening/eyecontact)tovoice(10seconds)

Noresponsetovoiceorphysicalstimulation

ProcedureforRASSAssessment
1. Observepatient

Patientisalert,restless,oragitated.(Score0to+4)
2. Ifnotalert,statepatientsnameandsaytoopeneyesandlookatspeaker.
Patientawakenswithsustainedeyeopeningandeyecontact.(Score1)
Patientawakenswitheyeopeningandeyecontact,butnotsustained.(Score2)
Patienthasanymovementinresponsetovoicebutnoeyecontact.(Score3)
3. Whennoresponsetoverbalstimulation,physicallystimulatepatientbyshakingshoulder
and/orrubbingsternum.
Patienthasanymovementtophysicalstimulation.(Score4)
Patienthasnoresponsetoanystimulation.(Score5)
4. Importanttoconductatleastevery6hours,andasneeded,tomeasuretheresponseto
changesinsedationand/oropioidtherapy

ElyEW,etal.JAMA.2003;289:29832991.
SesslerCN,etal.AmJRespirCritCareMed.2002;166(10):13381344.

SedationAgitationScale(SAS)
Score

State

Behaviors

DangerousAgitation

PullingatETtube;tryingtoremovecatheter(s);climbing
overbedrail;strikingatstaff;thrashingsidetoside

VeryAgitated

Agitated

CalmandCooperative

Sedated

Difficulttoarouse;awakenstoverbalstimuliorgentle
shakingbutdriftsoffagain;followssimplecommands

VerySedated

Arousestophysicalstimulibutdoesnotcommunicate
orfollowcommands;maymovespontaneously

Unarousable

Minimalornoresponsetonoxiousstimuli;doesnot
communicateorfollowcommands

Doesnotcalmdespitefrequentverbalremindingof
limits;requiresphysicalrestraints;bitingETtube
Anxiousormildlyagitated;attemptingtositup;calms
downtoverbalinstructions
Calm;awakenseasily;followscommands

RikerRR,etal.CritCareMed.1999;27:13251329.
BrandlK,etal.Pharmacotherapy.2001;21:431436.

YES

RASS = zero

0-1
Error

> 1 Error

RASS other
than zero

0-2
Errors

NO

Copyright 2002, E. Wesley Ely, MD, MPH and Vanderbilt University, all rights reserved

Command: Hold up this many fingers (Hold up 2 fingers)

Now do the same thing with the other hand (Do not demonstrate)
OR Add one more finger (If patient unable to move both arms)

1. Will a stone float on water?

2. Are there fish in the sea?
3. Does one pound weigh more than two?
4. Can you use a hammer to pound a nail?

4. Disorganized Thinking:

> 2 Errors

If unable to complete Letters Pictures

3.Altered Level of Consciousness

Current RASS level

Squeeze my hand when I say the letter A.

Read the following sequence of letters: S A V E A H A A R T

ERRORS: No squeeze with A & Squeeze on letter other than A

2. Inattention:

Is there an acute change from mental status baseline? OR

Has the patients mental status fluctuated during the past 24 hours?

1. Acute
Change or Fluctuating Course of Mental Status:

CAM-ICU negative
NO DELIRIUM

CAM-ICU positive
DELIRIUM Present

CAM-ICU negative
NO DELIRIUM

CAM-ICU negative
NO DELIRIUM

Confusion Assessment Method for the ICU (CAM-ICU) Flowsheet

IntensiveCareDeliriumScreeningChecklist(ICDSC)
Scoreyourpatientovertheentireshift.Componentsdontallneedtobepresentatthesametime.
Components#1through#4requireafocusedbedsidepatientassessment.Thiscannotbecompletedwhen
thepatientisdeeplysedatedorcomatose(i.e.,SAS=1or2;RASS=4or5).
Components#5through#8arebasedonobservationsthroughouttheentireshift.Informationfromthe
prior24hours(i.e.,fromprior12nursingshifts)shouldbeobtainedforcomponents#7and#8.
1. Alteredlevelofconsciousness
Deepsedation/comaoverentireshift[SAS=1,2;RASS=4,5]
Agitation[SAS=5,6,or7;RASS=14]atanypoint
Normalwakefulness[SAS=4;RASS=0]overtheentireshift
Lightsedation[SAS=3;RASS=1,2,3]

=Notassessable
=1point
=0points
=1point(ifnorecentsedatives)
=0points(ifrecentsedatives)

No

1 Yes

No

1 Yes

No

1 Yes

No

1 Yes

No

1 Yes

No

1 Yes

No

1 Yes

No

1 Yes

2. Inattention
Difficultyfollowinginstructionsorconversation;easilydistractedbyexternalstimuli.
WillnotreliablysqueezehandstospokenletterA:SAVEAHAART
3. Disorientation
Inadditiontoname,place,anddate,doesthepatientrecognizeICUcaregivers?
Doespatientknowwhatkindofplacetheyarein?(Listexamplessuchasdentistsoffice,
home,work,hospital.)
4. Hallucination,delusion,orpsychosis
Askthepatientiftheyarehavinghallucinationsordelusions(e.g., tryingtocatchan
objectthatisntthere).
Aretheyafraidofthepeopleorthingsaroundthem?
5. Psychomotoragitationorretardation
EITHER:Hyperactivityrequiringtheuseofsedative drugsorrestraintstocontrol
potentiallydangerousbehavior(e.g.,pullingIVlinesoutorhittingstaff).
OR:Hypoactiveorclinicallynoticeablepsychomotorslowingorretardation.
6. Inappropriatespeechormood
Patientdisplaysinappropriateemotion,disorganizedorincoherentspeech,sexualor
inappropriateinteractions,orisapatheticoroverlydemanding.
7. Sleepwakecycledisturbance
EITHER:Frequentawakening/<4hourssleep atnight.
OR:Sleepingduringmuchoftheday.
8. Symptomfluctuation
Fluctuationofanyoftheabovesymptomsovera24hourperiod.

TOTALSHIFTSCORE

(Min0Max8)

Score
0
13
48

BergeronN,etal.IntensiveCareMed.2001;27:859864.
OuimetS,etal.IntensiveCareMed.2007;33:10071013.
AdaptedwithpermissionfromJohnDevlin,PharmD,FCCM,FCCP;TuftsMedicalCenter.

Classification
Normal
SubsyndromalDelirium
Delirium

Wake Up and Breathe Protocol

Spontaneous Awakening Trials (SATs) + Spontaneous Breathing Trials (SBTs)

SAT Safety Screen

every 24 hrs

SAT Safety
Screen
fail

No active seizures
No alcohol withdrawal
No agitation
No paralytics
No myocardial ischemia
Normal intracranial pressure

pass
Perform SAT

SAT Failure
Anxiety, agitation, or pain
Respiratory rate > 35/min
Oxygen saturation < 88%
Respiratory distress
Acute cardiac arrhythmia

Restart sedatives
at 1/2 dose

fail

pass
SBT Safety Screen

SBT Safety
Screen
fail

No agitation
Oxygen saturation 88%
FiO2 50%
PEEP 7.5 cm H2O
No myocardial ischemia
No vasopressor use
Inspiratory efforts

pass
Perform SBT

Full ventilatory
support

fail
pass
Consider
extubation

SBT Failure
Respiratory rate > 35/min
Respiratory rate < 8/min
Oxygen saturation < 88%
Respiratory distress
Mental status change
Acute cardiac arrhythmia

2008 Vanderbilt University. All rights reserved.

ProgressiveMobilityProtocol

Passiverangeofmotion(ROM)therapyisstartedonday1ofprotocol(levelI).Aspatients
demonstrateconsciousnessandincreasedstrength,theymovetothenexthigherlevel.Physical
therapy(PT)isfirstattemptedatlevelII.Interventionisceasedaspatienttransferstogeneral
carearea;patientswithinbothprotocolandusualcaregroupsreceiveusualcaremobility
therapy(MT)asdictatedbyphysicianteamsingeneralcareareas.OOB=outofbed.
RossAG,MorrisPE.CritCareNurse.2010;30(2suppl):S11S13.

Exercise/Mobility Screening and Therapy

Step 1: Exercise/Mobility Safety Screen (Patients must pass this safety screen in order to get therapy)
M Myocardial stability
o No evidence of active myocardial ischemia (24 hrs)
o No arrhythmia requiring the administration of a new antiarrhythmic agent (24hrs)
O Oxygenation adequate on
o FIO2 <0.6
o PEEP <10 cm H2O
V Vasopressor(s) minimal
o No increase dose of any vasopressor infusion for at least 2 hours
E Engages to voice
o Patient responds to verbal stimulation (i.e., RASS > -3); range of motion may be performed in
comatose patients, but will not be considered part of the Early Exercise Protocol (Some
protocols may expand to include range of motion in comatose patients)
If the patient fails the Exercise/Mobility safety screenIf a patient does not meet all of the criteria
above then he/she fails the safety screen and should not have the Exercise/Mobility protocol
performed. In essence the patient is to critically ill to tolerate exercise and/or movement.
If the patient passes the Exercise/Mobility safety screen If a patient meets all of the safety criteria
then he/she may move to Step 2: Exercise/Mobility Therapy

Step 2: Exercise/Mobility Therapy Once patients pass the safety screen they mayprogress to have
therapy performed. Therapy should be started at Level 1 (see listing below) and progress as the patient
tolerates to Level 4; however, completion of any activity listed below is considered compliant with
Exercise/Mobility Therapy. All events can be performed with assistance. The activities can be
performed by bedside staff, including but not limited to the RN, PT, and OT as well as family members
and patients themselves.
Levels of Progressive Mobility:
Level 1: Active ROM exercises in bed and/or sitting position in bed; this includes bed adjustment,
passive transfer, or with lift assistance
Level 2: Dangling
Level 3: Transfer to chair (active), includes standing without marching in place
Level 4: Ambulation (marching in place, walking in room/hall)

PointstoConsiderWhenImplementingtheABCDEBundle

SpontaneousAwakeningTrialand
SpontaneousBreathingTrialCoordination
Timingoftrials:Theoptimaltimingoftrials(nightordayshift)isyettobedetermined.Itisalsounclearwhether
performingmultipletrialsin1dayisbeneficialordetrimentaltopatientoutcomes.
Performingtrialsonthenightshiftmaybepracticalbecauseofworkloadrelatedissues(e.g.,lessoffunittime,
distractions,andtasks)oriftheinstitutionhasexperienceandsuccessperformingthematthistime.However,itis
possiblethatperformingtrialsatthistimemayinterferewithsleeppatterns.
Performingtrialsondayshiftmaybemorepracticalbecausephysiciansarepresentandmaybemorewillingtomake
thedecisiontoextubateatthetimeofSBTpass.Therearealsomorepeoplepresentduringtheday,whichmaybe
beneficialifassistanceisneeded(e.g.,patientdoesnottoleratethetrial).Yet,performingtrialsduringthedaymight
bedifficultduetostaffingchallengesandtheneedtoperformnumerousothertasks(e.g.,earlymobilization).
Knowledgedeficits:Anticipatetheneedtoaddressseveralkeypoints,including:
Weaningparametersnolongerbeingnecessary
Risksofoversedation
Fearofincreaseinadverseevents(e.g.,selfextubation,falls,hemodynamicinstability)
Misperceptionsregardingprotocol(e.g.,notbeingabletoprovideopioidsforpain,futilityofrestartinginfusionsat
halfthepreviousrate,thatisbettertousecontinuouslyinfusedsedativesvs.PRNsedation)
Rolesedativesplayinsleeppatterns.
Safetyscreenquestionsandpass/failcriteria:Carefullyreviewexistingstudiesanddiscussapplicabilitytocertain
populations(e.g.,neurosurgical,patientswithopenabdomens).Clearlydelineatethestepsandcriteriainvolvedinthe
process.Encouragediscussionandcometoagreementonbenefitsandrisksofaddingmoreexclusioncriteria.
Documentation:BeforecreatinganABCDEbundlepolicy,carefullyreviewanyexistingpoliciesandproceduresfor
duplication,redundancy,orcontraindications.AllABCDEbundlerelateddocumentationshouldbeviewablebyother
disciplines.Consideraddinganopenendedfieldtosafetyscreenandpass/failcriteriasothatclinicianscandocument
whyproceduresthatfelloutsidenormalcriteriawerenotperformed.Anticipatereluctancetouseanynewformof
documentation.
Communication:EncourageRNsandRTstocollaborativelydetermineoptimaltimingoftrials.Discussresultsoftrialsdaily
oninterdisciplinaryrounds.Determinewhowillfollowoutcomesandadherencetotrials.Discusswhowillholdclinicians
accountableforperformingproceduresonadailybasis.
Decidewhethertoadoptanoptoutmethod:DecideearlywhetherRNsandRTswillbeempoweredtoimplement
protocolsknowntobenefitpatients,ratherthanwaitforaphysiciantoordertrialsonadailybasis.

Deliriummonitoring/management
Assessment:Determinethefrequencyofdeliriumandsedation/agitationassessmentandwhichscreeninginstrumentwill
beused.
Education:Decidethemethod(e.g.,casestudies,trainthetrainer),frequency,andmodality(e.g.,inperson,online)of
deliriumeducation.Deliriumpreventionandtreatmentstrategies(pharmacologicandnonpharmacologic)needtobe
developedandrolledouttoallmembersoftheinterprofessionalteam.Longstandingmythsregardingdeliriumneed
tobeidentifiedandaddressed(e.g.,thatitisnormalforolderadultstobecomeconfused,thatdeliriumhasnolongterm
consequence).DoNOTunderestimatetheamountofeducationthatwillbeneededtoaddressthispartofthebundle.

EarlyMobility
Safetyscreenquestionsandpass/failcriteria:Carefullyreviewexistingmobilitystudiesanddiscussapplicabilitytocertain
populations(e.g.,neurosurgical,patientswithopenabdomens,etc.).Clearlydelineatethestepsandcriteriainvolvedin
theprocess.Encouragediscussionandcometoagreementonthebenefitsandrisksofaddingmoreexclusioncriteria.

AdaptedfromBalasMC,BurkeWJ,GannonD,etal.ImplementingtheABCDEbundleintoeverydaycare:opportunities,challengesand
lessonslearnedforimplementingtheICUpain,agitationanddelirium(PAD)guidelines.CritCareMed.Inpress.