Delirium Prevention and Safety:
Starting with the ABCDE’s
It is essential to consider delirium management in the broader picture of ICU patient care as a major piece of the current guidelines for Pain, Agitation, and Delirium (PAD) of the Society of Critical Care Medicine (SCCM). Advancements in research and technology are resulting in higher acuity and increased complexity of care, which is resulting in drastic increases in workload and demands on staff. More than ever, there is a great need to develop simpler ways of implementing safer and better care into practice for our sickest patients.
The ABCDE bundle is one way to align and coordinate care, which includes specific focus on delirium as a component of the overall care patients receive including sedation and pain medications, breathing machines, and mobilization. This bundle has multiple, evidenced based components, interdependent, and designed to:
- Improve collaboration and coordination among clinical team members
- Standardize care processes
- Decrease delirium
- Break the cycle of oversedation and prolonged ventilation
What are the components of the ABCDE bundle?
(See menu on the left for more information on each component)
Think of the ABCDEs as a means of putting best practice into the real world of your ICU. Why use a mnemonic? Because it provides a sticky (i.e., easy to remember) message, and it is evidence based (all created from data published in high impact journals such as JAMA, Lancet, and NEJM). Outcomes of mechanically ventilated patients can be improved if the interventions described in the ABCDE approach are used together as a bundle (M Balas CCM, 2013 in press) and discussed regularly on rounds with your interdisciplinary team. To ensure that bundles remain scientifically credible and have the maximum possible impact on outcomes, periodic updating based on new evidence is critical. The ABCDE bundle, in accordance with the Society of Critical Care Medicine’s 2013 Clinical Practice Guidelines for the Management of Pain/Agitation/Delirium (PAD) in Adult ICU Patients, must include routine pain, agitation, and delirium screening and management through the use of valid and reliable tools. These tools are well outlined in the PAD Guidelines and many are available on this website.
So what is a BUNDLE anyway?
This is a published conversation that took place within the largest quality improvement organization in the U.S. called the Institute for Healthcare Improvement (IHI). The IHI's Rethinking Critical Care program has incorporated concepts related to the ABCDEs and the PAD Guidelines that can be found on their secure website.
Three commonly misunderstood aspects of the ABCDEs are as follows:
- MYTH: The ABCDEs and PAD are advocating different things.
- TRUTH: These are similar constructs. As noted above, think of the ABCDEs as a way of operationalizing the 2013 PAD guidelines. There are many ways of going about this; the ABCDE Bundle is just one way of talking about and organizing this “new culture” of lighter sedation, attention to delirium, and early mobility. Just like the PAD does advocate early mobility even though mobility is not explicitly stated in the title, so Pain is also included in the ABCDEs even though that mnemonic doesn’t include a “P.”
- MYTH: Pain is not a part of the ABCDEs.
- TRUTH: The “Pain” piece is not explicitly given a “letter” in the ABCDE mnemonic, yet it is and always has been an integral component of this management plan for patients. In the original ABC study we published in Lancet (Girard T et al, 2008, see Timeline), we never turned off opioids or other analgesics unless the pain assessment by the nurse revealed adequate pain control.
- MYTH: If an ICU is not completely turning off sedative medications, it is not embracing SATs or the ABCDEs.
- TRUTH: The original ABC study, as well as other subsequent publications and quality improvement projects have prioritized the concept of a “complete shut off” of sedation and analgesia once the patient is felt to be pain free and passes the SAT safety screen. However, there are hospitals in general or specific patients in whom a reduction in sedative dose without a complete shut-off is indicated for safety reasons. This SAT and SBT approach supported by the NEJM and Lancet studies is not a “one shoe fits all.” We must use clinical judgment. If the reason we are leaving the potent sedative medications going in our patients is mostly because “that is our culture” or the staff are too busy to deal with an interactive patient, then that likely needs to be re-evaluated and solutions found.
AACN Resources: Implementing the ABCDE Bundle at the Bedside
The American Association of Critical Care Nurses (AACN) has put together a toolkit for implementing the ABCDE bundle at the bedside. This toolkit includes both resources for the specific components of the bundle as well as tools for change/implementation. It has been endorsed by the Agency for Healthcare Research and Quality (AHRQ)AACN ABCDE Implementation Toolkit
Reducing iatrogenic risks: ICU-acquired delirium and weakness-crossing the quality chasm.Vasilevskis EE et al. Chest. 2010
Read on PubMed.gov
Critical Care Nurses’ Role in Implementing the ABCDE BundleBalas MC et al., Crit Care Nurse. 2012
Read on PubMed.gov
Implementing the 2013 PAD guidelines: top ten points to consider.Pun BT, Balas MC, Davidson J, Semin Respir Crit Care Med. 2013
Read on PubMed.gov
Brain Disorders in Critical IllnessFirst ever comprehensive textbook in this field of critical illness brain injury.
View on Amazon.com
Delirium in Critical CareSuccinct handbook on ICU Delirium
View on Amazon.com