【體外膜肺ECMO精品課件】-Applying-the-“ABCDE”-Bundle-into-Cl

1、【體外膜肺ECMO精品課件】 Applying the “ABCDE” Bundle into Clinical PracticeEpidemiology ICU-Acquired Delirium & WeaknessDelirium20-50% non-MV ICU81-83% MV ICU 50-80% S/T/B ICU ICU Acquired Weakness (AW)25-50% of all patients who receive MV for 4-7 day50-75% sepsis patients University of Nebraska Medical Cente

2、rOUTCOMES ASSOCIATED WITH DELIRUM10-fold risk of in-hospital deathEach additional day of delirium risk of dying 10%Increased risk of:Prolonged ICU & hospital LOS Nosocomial complicationsGreater use of continuous sedation & physical restraintsIncreased self-removal of catheters & ETTsUniversity of Ne

3、braska Medical CenterOUTCOMES ASSOCIATED WITH DELIRIUMPoor functional recovery & loss of independenceRisk of death up to 2 years following dischargePost-acute care nursing-home placementLong-term cognitive impairmentTotal 1-year health-care costs of delirium $38 billion to $152 billion nationallyHip

4、 fracture-$7, falls $19 billion, diabetes $91 billion, CV disease $257 billionUniversity of Nebraska Medical CenterOUTCOMES ASSOCIATED WITH ICU-AW80-95% of patients with ICU-AW have neuromuscular abnormalities 2-5 YEARS after discharge70% of MV patients have difficulty with ADLs 1 year after dischar

5、geUniversity of Nebraska Medical CenterICU OUTCOMES30-80% of ALL patients have cognitive impairment after ICU dischargeSome improve within 1 year, but many others NEVER return to baseline level10-50% of ICU survivors experience PTSD, depression, anxiety, & sleep disordersProblems may persist years a

6、fter discharge50% of ALL ICU survivors require caregiver assistance 1 year after dischargeUniversity of Nebraska Medical CenterWHO IS RESPONSIBLE FOR IMPROVING OUTCOMES?NursesRespiratory TherapistsPhysical TherapistsPharmacistsMedical DoctorsAdministrationUniversity of Nebraska Medical CenterStudy A

7、imsImplement the ABCDE bundle in a medical center that does not currently perform routine ICU delirium screenings & identify facilitators & barriers to program adoptionTest the impact of the ABCDE program on patient, nursing quality, & system outcomesAssess the extent to which ABCDE implementation i

8、s effective, sustainable, & conducive to dissemination into other settingsUniversity of Nebraska Medical CenterOUR TEAMUniversity of Nebraska Medical CenterTHE STORYWHAT WE KNEWAdministrative “buy-in”O(jiān)pen ICUsCCS deliveryCurrent policyResearch vs. practiceOutcomes of interestIRBSubject recruitment U

9、niversity of Nebraska Medical CenterTHE STORYWHAT WE DIDSynthesis & presentation of ABCDE bundleInterprofessional focus groupsKnowledge deficitsCommunication challengesDocumentationCurrent policyApplicabilityAccountabilityStaffing ratios/patternsUniversity of Nebraska Medical CenterTHE STORYWHAT WE

10、DIDDeveloped TNMC policyContinual staff feedbackCommittee approvalEducation, Education, EducationVisiting professorInterprofessional in-services8 hour nursing in-serviceTechnologyOn-line, interprofessional, CE creditsUniversity of Nebraska Medical CenterTHE STORYTHIS IS WHAT “WE” DEVELOPEDTNMC ABCDE

11、 BUNDLEPurposeTo who do is it apply?Opt “out” vs. opt “in” policy3 distinct, yet highly interconnected componentsAwakening & Breathing trial CoordinationDelirium monitoring & managementEarly mobilityUniversity of Nebraska Medical CenterABC “STEPS”Spontaneous Awakening Trial Safety ScreenRN DrivenSpo

12、ntaneous Awakening TrialRN DrivenSpontaneous Breathing Trial Safety ScreenRT DrivenSpontaneous Breathing Trial RT DrivenUniversity of Nebraska Medical CenterUniversity of Nebraska Medical CenterStep 1 SAT Safety Screen-RN DrivenSAT Safety Screen QuestionsIs patient receiving a sedative infusion for

13、active seizures?Is patient receiving a sedative infusion for ETOH withdrawal?Is patient receiving a paralytic agent?Is patients RASS score 2?Is there documentation of myocardial ischemia in the past 24 hours?Is patients ICP 20?Is patient receiving sedative medications in an attempt to control intrac

14、ranial pressures?Is patient currently receiving ECMO?All SAT Safety Screen Questions answered NO: Conclude it is SAFE to perform a SAT Turn off all continuous sedative infusions Hold all sedative boluses PRN analgesics allowedContinuous analgesic infusions maintained only if needed for active pain P

15、roceed to Step 2Any SAT Safety Screen Questions answered YES: Conclude it is NOT SAFE to shut off patients continuous analgesic or sedative infusions Continue the patients regimen & reassess in 24 hours Discuss the patients condition during interdisciplinary roundsSAT Failure QuestionsRASS score 2 f

16、or 5 minutes Sa02 5 minutesRespirations 35 BPM for 5 minutesNew Acute Cardiac ArrhythmiaICP 202 or more of the following symptoms of respiratory distress: HR increase 20 or more BPM, HR 55 BPM, Use of accessory muscles, Abdominal paradox, Diaphoresis, DyspneaIf patient able to open his/her eyes to v

17、erbal stimulation without failure criteria (regardless of trial length) OR does not display any of the failure criteria after 4 hours of shutting of sedation: Any SAT Failure Criteria Questions answered YES:Step 2-Perform SAT-RN Driven- Conclude the patient has FAILED the SAT- Restart the patients s

18、edation at the previous dose & then titrate to sedation target- Interdisciplinary team will determine possible causes of the SAT failure during rounds- Repeat Step 1 in 24 hours - Conclude the patient has PASSED the SAT - RN will ask the RT to immediately perform a SBT safety screen Step 3SBT Safety

19、 Screen QuestionsIs patient a chronic/ventilator dependent patient?Is patient SpO2 50%?Is patients set PEEP 7?Is there documentation of myocardial ischemia in the past 24 hours?Is the patient currently on vasopressor medications?Is patients intracranial Pressures 20?Is patient receiving mechanical v

20、entilation in an attempt to control ICP?Does the patient lack inspiratory effort?All SBT Safety Screen Questions answered NO:Conclude it is SAFE to perform a SBTProceed to Step 4Any SBT Safety Screen Questions answered YES:Conclude it is NOT SAFE to perform a SBTContinue mechanical ventilation & rep

21、eat step 3 in 24 hoursRT will ask the RN to restart sedatives at the previous dose only if neededDiscuss the patients condition during interdisciplinary roundsStep 3-Perform SBT Safety Screen-RT DrivenStep 4-Perform SBT-RT Driven Any SBT Failure Criteria Questions answered YES:Conclude the patient h

22、as FAILED the SBTRestart mechanical ventilation at previous settingsRepeat step 3 in 24 hoursAsk RN to restart sedatives at the previous dose only if neededDetermine possible causes of the SBT failure during interdisciplinary roundsIf the patient tolerates the SBT for 30-120 minutes without failure

23、criteria Conclude the patient has PASSED the SBTInform the physician that the patient has PASSED the SBTPhysician should consider extubationSBT Failure QuestionsRespirations 35/minute for 5 minutes Respiratory rate 8Sp02 202 or more of the following symptoms of respiratory distress: Accessory Muscle

24、 use, Abdominal Paradox, Diaphoresis, Dyspnea, Mental status changes, Acute cardiac arrhythmiaWHY IS DELIRIUM SO CONFUSING?University of Nebraska Medical CenterAcute ConfusionSun-downingICU psychosisToxic or metabolic encephalopathyDementiaCerebral insufficiencyAcute brain dysfunctionAltered mental

25、statusOrganic brain syndrome“Just aint right”Delirium Monitoring & ManagementRoutine Sedation & Delirium Assessment Using Standardized, Validated Assessment ToolsRN administers & records RASS results q2hTeam sets “target” RASS score for the patient to be maintained at for the following 24 hoursRN ad

26、ministers & records results of the CAM-ICU q8h & whenever a patient experiences a change in mental statusWhat is the CAM-ICU? Delirium Monitoring & ManagementEach day during interdisciplinary rounds, the RN will:State the “TARGET” RASS score State the patients ACTUAL RASS scoreState the CAM-ICU stat

27、usState the sedative/analgesic medications the patient is currently receivingEach day during interdisciplinary rounds, the team will use the acronym “THINK” if a patient is CAM positive (delirious)The interdisciplinary team will employ the following non-pharmacologic interventions when treating a de

28、lirious patient:Eliminate or minimize risk factors Provide a therapeutic environment 1. Where is the patient going?Target RASS2. Where is the patient now?Current RASSCurrent CAM-ICU3. How did they get there?DrugsBrain Road MapNONPHARMACOLOGIC APPROACHES TO PREVENTING & TREATING DELIRIUMUSE MEDICATIO

29、NS ONLY IF ABSOLUTELY NECESSARY!Give “PEACE” a chancePhysiologicEnvironmentalADLs/SleepCommunicationEducationUniversity of Nebraska Medical CenterEarly Mobility-Safety Screen-RN DrivenN Neurologic Patient response to verbal stimulation (i.e. RASS -3)Activity not started in comatose patients (RASS -4

30、 or -5)R RespiratoryFIO20.6 PEEP10 cm H2OC CirculatoryNo increase dose of any vasopressor infusion for at least 2 hoursNo evidence of active myocardial ischemiaNo arrthymia requiring the administration of a new antiarrythmic agent Not receiving therapies that restrict mobility ECMO, Open-abdomen, ICP monitoring/drainage, Femoral arterial line If Early Mobility Safety Screen criteria are MET :-Conclude it is SAFE to begin early mobility protocol If Early Mobility Safety Screen criteria are NOT MET :Conclude it is NOT SAFE to begin early mobility protocolContinue patients regimen & reassess i