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ICU Part 2

The Intensive Care Unit – Part 2 – Dennis M., Occupational Therapist

The ABCDE Bundle is a set of practices known as: Awakening, Breathing Coordination, Delirium monitoring, Exercise/Early mobility.  Sedative selection and management are leading modifiable risk factors for preventing delirium in the ICU. Sedative drugs are universally used in critically ill patients to reduce the work of breathing and alleviate agitation.

Research suggests that benzodiazepines pose the highest risk for patients developing delirium and prevents patient mobility. Research studies suggest daily spontaneous awakening trials (SATS) to facilitate transition from drug-induced coma to consciousness to reduce the duration of mechanical ventilation and ICU complications as well as costs.

Terminating mechanical ventilation requires objective assessment for patient readiness, best performed by daily SBT’s (spontaneous breathing trials) in patients meeting established safety criteria. Numerous research studies confirmed nonphysician protocolized management of SBT’s resulted in no loss of safety, while simultaneously increasing nonphysician provider autonomy. Also these studies high-lighted the importance of interdisciplinary coordination of sedation and ventilation between respiratory therapists and nurses, which led into the coordination of daily awakening and daily breathing trials.

Delirium monitoring is a guideline recommended practice using the “Intensive Care Delirium Screening Checklist and the Confusion Assessment method for the ICU (CAM-ICU)”.Exercise/Early Mobility of ICU patients reduces acute cognitive and physical dysfunction. Numerous research studies have demonstrated early Physical & Occupational therapy has been shown to reduce hospital length of stay up to three days reduce delirium incidence and increase return to independent functioning of ADL’s.

The use of Physcial & Occupational therapy targeted toward ICU patients is increasing common, but not uniform and faces many barriers, including competing processes of care, lack of early mobilization care planning and inadequate technology and/or collaboration.

The institute of Medicine 2001 landmark report “Crossing the Quality Chasm: A new health system for the 21st century”, stated that health care today harms too frequently and routinely fails to deliver potential benefits. Although great strides have been made in improving the quality and safety of critical care, adherence to recommended strategies of ICU care remains inadequate. The ABCDE  Intervention Bundle is one important approach to cross this quality chasm.”

For more information on this topic and more specifics on implementing the ABCDE Intervention Bundle please consult the following two articles: “Reducing Iatrogenic Risks: ICU Acquired Delirium and Weakness: Crossing the Quality Chasm” Chest: 2010: 138:1224-1233 and “Critical Care Nurses: Role in Implementing the ABCDE Bundle into Practise” Critical Care Nurse: Vol 32: No. 2 April 2012 page 35-47.