Lab group B: Allysa Neri, Jessica Farrone, Alana

Mendoza, Lizette Rodriguez, Meseret Patterson,

Gabriella Harrington, and Becky Miller
z
The ABCDE
Bundle on
Delirium in the
ICU
z
Introduction-Description of Issue
• There is a high prevalence of patients developing delirium in the ICU
•Especially high when a patient is sedated, on mechanical ventilation and
are immobile [2]
•Delirium has poor effects on patient outcomes [8]
•Medication is sometimes used for delirium prevention and treatment
•Benzodiazepines
•One study does not support the use of medication due to lack of
evidence and risk for harm [6]
•Benzos can contribute to development of delirium [11]
•Our research: ABCDE bundle to prevent and shorten duration of delirium
•Awakening, Breathing, Coordination, Delirium monitoring and
management, and Early mobility [1]
•Better outcomes
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z z
Introduction-Significance in Nursing

All patients, not just ICU, could develop delirium

 Applicable to every area in the hospital
 Very prevalent in the ICU
Know evidence-based ways to help prevent
delirium to reduce the duration of hospital stays
 Look at specific hospital policy for delirium
management
 Could be implemented currently in hospital or in
the future
Alternative methods to medications
 Reduce hospital and patient costs
 Lessens adverse effects of multiple medications
 z
PICOT Question
In long term ICU patients, does the implementation of the ABCDE bundle,
which includes awakening, breathing, coordination, delirium monitoring and
management, and early short distance mobility, compared to the
pharmacological method of benzodiazepines positively affect the morbidity
rate, mental status and decrease length of stay in the ICU?

 •What is the best practice for delirium prevention, treatment, and its relation
to patient outcomes?

 •Keywords searched: delirium, ICU, ABCDE bundle, benzodiazepines, cost

 •Databases searched: CINAHL, PubMed, Google Scholar, ClinicalKey

 z Summary of Current Practice
 Banner University Medical Center (Maria, Personal Communication, March 21,
2018)

 Northwest Medical Center (Jessica, Personal Communication, March, 22, 2018)

 Tucson Medical Center (Sarah, Personal Communication, March 21, 2018)

 Carondelet St. Joseph’s Hospital (Maria, Personal Communication, March 21, 2018)

 Carondelet St. Mary’s Hospital (Cherise, Personal Communication, March 22, 2018)
 z
Summary of Current Practice
 State
 Flagstaff: Flagstaff Medical Center (Lassie, Personal Communication, March 21, 2018)
 Phoenix
 Chandler Regional Medical Center (Amanda, Personal Communication, March 21,
2018)
 Mayo Clinic (Katie, Personal Communication, March 21, 2018)
 Dignity Health St. Joseph Hospital (Elizabeth, Personal Communication, March 21,
2018)
 Yuma: Yuma Regional Medical Center (Jane, Personal Communication, March 21, 2018)
 National
 Nebraska [1] [2]
 Tennessee [1] [2]
 Florida [9]
 Ohio [2]
 Rural hospitals in Maryland [3] [8]
 Boston, Massachusetts [1]
 z
Synopsis of Current Literature

 Patient’s overall outcome

 Decrease in the length of stay in the ICU
 Duration of ventilation was decreased
 The use of sedatives were decreased
 Prevalence of delirium
 Mobilization

 Cost effective
 Pain, Agitation, and Delirium (PAD)
 Health-care providers
 z Summary
z of Strengths
 Use of standardized bedside instrument
 Examples:
 RASS
 CAM-ICU
 Functional Independence Measure (FIM)

 Participation of disciplinary team

 Nurses
 Physicians
 Physical therapist
 Pharmacists
 Patient care techs https://www.vectorstock.com/royalty-free-vector/medical-
team-isolated-on-white-vector-16659271

 Respiratory therapists
 Nursing care Coordinator
 z Summary of Strengths Cont...

 Comprehensive review of pertinent  Implementation of multi-bundle

literature to help with design of study education and training

 Evaluated multiple factors  One day classes

 Medications: Benzodiazepines  Long, intensive training

 Severity of illness  Survey of opinions and

understanding
 Pain
z
Summary of Limitations
 Many of the studies took place in a single-centered medical
institution, with small sample sizes
 The results were not able to be generalized

 Time and staff required

 More staff/time required

 More documentation

 Reluctance to implement change from medical team

 Compliance?

 Many reported less reluctance with increase of positive results.

 z
Evidence-Based Nursing Recommendations
From the articles that were researched it is shown that
the ABCDE bundle results in reduced time on ventilators,
decreased delirium, and increased mobility compared to
patients not treated with the bundle.
 It is recommended to assess SAT and SBT scores every 24
hours for early reduction of sedatives and ventilators [7]
 ICU patients using the CAM-ICU scale at least once a shift to
assess for delirium [7]
 It is recommended to implement early mobility to decrease
delirium, length of stay and days on ventilators [7]
 z
Implementation to Nursing Practice
January 10, 2018 - April 30, 2018 : Research and implementation planning

May 1, 2018 – September 30, 2018: Patient-centered “ABCDE bundle” team will be

created

October 1, 2018 - October 31, 2018 : “ABCDE bundle” team training

November 1, 2018 – April 1, 2019: Nursing staff, respiratory therapists, and

rehabilitation staff will partake in training during normal working hours

April 2, 2019 – April 2, 2020: Implementation of the bundle and data collection

April 3, 2020 – June 3, 2020: Implementation team will conduct a data analysis
z
Cost Analysis

 Every year $6.5 to $20.4 billion is spent in providing

care for mechanically ventilated delirium patients in the
United States [8].

 The cost of patient care in individuals with delirium is

2.5 times higher per day than those who don’t have
delirium [8].

 The care of a patient with delirium sometimes

continues up to 9 months after discharge from the
acute care setting [8].
 z

Cost of Implementation

 In a community of 3 rural hospital ICU’s the ABCDE bundle was implemented in 2014
[8].
 There weren’t costs for implementation of the new practice into the facility except for
the time to train the ABCDE bundle multidisciplinary team [8].

 Average median salary to be paid during training: Nurse: $33/hr, Respiratory Therapist:
$28/hr, Occupational therapist: $39/hr, Physical Therapist: $41/hr, Pharmacist: $59/hr,
Physician: $100/hr which is an average daily rate of: $264-$800 per individual [4].

 There was no need to acquire any additional supplies or equipment [8].

z
Effect of implementation on Cost

 When the ABCDE bundle was implemented the incidence

and duration of delirium among patients declined [8].

 The patient length of stay in the ICU and overall hospital

stay declined [8].

 The amount of time that the patient was on a mechanical

ventilator and sedated decreased which saves
approximately $700 per patient [8].

 The overall hospital stay decreased by an average of 1.8

days leading to an average savings of $2,156 per patient [8].
 z
Effect of implementation on cost-
Pharmacy
 Benzodiazepines cost an average of $7/60 pills or
12¢/pill which are given an average of three times
per day leading to a daily cost of 36¢ per day [5].

 Pilot program at Florida Orlando Hospital tracked

the reduction of pharmacy costs and showed a
drug expense reduction of $4.3 million in 2014 [9].

 Projected to exceed $7.7 million in 2015 [9].

 z
Should we implement?
 The overall average cost saved yearly is $7.2-$12.3 million based on patient
population [5].
 Positive patient outcome of decreased incidence of delirium leading to less
future cost to the patient in follow-up and rehabilitation care.
 Based on the current evidence available and the positive patient and financial
outcomes realized from its implementation, the ABCDE bundle is a cost-
effective method that improves clinical outcomes in the adult ICU [8].
Risks and Benefits
z

Benefits for institution

 Length of stay
 Cost

Risks for Institution

 Implementation of new concepts
 Educational classes
 Compliance

Benefits for Nurses

 Nursing leaders
 Increase in clinical knowledge

Risks for nurses

 Increased workload for nurses
 Communication and Rounds
 Documentation
Risks and Benefits
z
Benefits for the patients
 Delirium
 Length of stay
 Mortality rates
 Cost
 Weakness, agitation, ventilator
 Autonomous and valued

Risk for patients

Some nurses thought ABCDE Bundle caused:
 Fatigue
 Emotional distress
 Physiological instability
 Psychological distress
 z
SMART Outcomes
We will implement the ABCDE bundle June 2, 2019 to June 2,
2020. Data will be collected and analyzed every month to
compare with the statistics from the same time period the
previous year. Improved outcomes will show:

– A 29% drop in ventilator days by 6 months.

– A 15% decline in delirium within 3 months of implementation

– A decrease in the average length of stay by 26% during the year of

implementation
 z
Summary
 Introduction:
 High prevalence of patients developing delirium in the ICU leading to poor patient outcomes

 Research:
 Shows a significant increase of positive outcomes with implementation of the ABCDE Bundle

 Description:
A. Spontaneous awakening trial (SAT)
B. Spontaneous Breathing Trial (SBT)
C. C- Coordination
D. D- Delirium Assessment (CAM-ICU) and management
E. E- Early mobility (EM)

 Our question:
 Will implementation of the ABCDE have a more positive affect on morbidity rate, mental status, and
decrease length of stay in ICU than the previously used pharmacological method.
 All of our articles were congruent in determining that implementation of the ABCDE Bundle is
more beneficial than pharmacological interventions that are currently being used.
 z
Summary cont...
 Application to facility:
 Over a span of two years and seventh months
 Research
 Training/education
 Implementation
 Data analysis

 Cost:
 Overall more cost-efficient compared to using pharmacological interventions, such as benzodiazepines
 $9-12.3 million hospital savings
 $2,156 saved per hospital stay

 Overall benefits and risks:

 Create a decrease in delirium, length of stay, mortality, cost
 Decrease in patient weakness, agitation, and days on ventilation
 Increase in clinical knowledge
 Concerns of
 Increased workload
 Emotional liability
 z References
1. Balas, M. C., Burke, W. J., Gannon, D., Cohen, M. Z., Colburn, L., Bevil, C., … Vasilevskis, E. E. (2013). Implementing the ABCDE Bundle into Everyday Care: Opportunities, Challenges and Lessons Learned
for Implementing the ICU Pain, Agitation and Delirium (PAD) Guidelines. Critical Care Medicine, 41(9), 116–127. doi: 10.1097/CCM.0b013e3182a17064

2. Balas, M., Vasilevskis, E., Olsen, K., Schmid, K., Shostrom, V., Cohen, M., . . . Burke, W. (2014). Effectiveness and safety of the awakening and breathing coordination, delirium monitoring/management, and
early exercise/mobility bundle. Critical Care Medicine, 42(5), 1024-1036. doi:10.1097/CCM.0000000000000129

3. Bounds, M., Kram, S., Speroni, K. G., Brice, K., Luschinski, M. A., Harte, S., & Daniel, M. G. (2016). Effect of ABCDE Bundle Implementation on Prevalence of Delirium in Intensive Care Unit Patients. American
Journal of Critical Care, 25(6), 535-544. doi:10.4037/ajcc2016209

4. Careeronestop.org, (2018). Salary Finder. Retrieved from https://www.careeronestop.org/Toolkit/Wages/find-salary.aspx

5. Good RX, INC, (2018). Benzodiazepines. Retrieved from https://www.goodrx.com

6. ICU Delirium and Cognitive Impairment Study Group, (2013). ABCDEFs of Prevention and Safety. Retrieved from http://www.icudelirium.org/earlymobility.html

7. Jin, Y. H., Li, N., Zheng, R., Mu, W., Lei, X., Si, J. H., . . . Shang, H. C. (2017). Benzodiazepines for treatment of delirium in non-ICU settings. Cochrane Database of Systematic Reviews. doi:10.1002/

8. Kram, S. L., DiBartolo, M. C., Hinderer, K., & Jones, R. A. (2015). Implementation of the ABCDE Bundle to Improve Patient Outcomes in the Intensive Care Unit in a Rural Community. Dimensions of Critical
Care Nursing, 34(5) 250-258 doi:10.1097/DCC.0000000000000129K

9. Louzon, P., Jennings, H., Ali, M., & Kraisinger, M. (2017). Impact of pharmacist management of pain, agitation, and delirium in the intensive care unit through participation in multidisciplinary bundle
rounds. American Journal of Health-System Pharmacy, 74(4), 253-262. doi:10.2146/ajhp150942

10. McPherson, J. A., Wagner, C. E., Boehm, L. M., Hall, J. D., Johnson, D. C., Miller, L. R., … Pandharipande, P. P. (2013). Delirium in the Cardiovascular Intensive Care Unit: Exploring Modifiable Risk
Factors. Critical Care Medicine, 41(2), 405–413. doi: 10.1097/CCM.0b013e31826ab49b14651858.cd012670

11. Sosnowski, K., Mitchell, M. L., White, H., Morrison, L., Sutton, J., Sharratt, J., & Lin, F. (2018). A feasibility study of a randomised controlled trial to examine the impact of the ABCDE bundle on quality of life in
ICU survivors. Pilot and Feasibility Studies, 4(1). doi:10.1186/s40814-017-0224-x

12. Zaal, I. J., Devlin, J. W., Hazelbag, M., Klouwenberg, P. M., Kooi, A. W., Ong, D. S., . . . Slooter, A. J. (2015). Benzodiazepine-associated delirium in critically ill adults. Intensive Care Medicine, 41(12), 2130-
2137. doi:10.1007/s00134-015-4063-z