Removing confusion from the Intensive Care Unit: implementing best practice to improve patient outcomes.
This is a patient recollection of her time in the intensive care unit (ICU), seemingly distanced and unaware of reality and unable to assist in her own recovery. As nurses and physicians work to keep sick patients alive and preserve organ function, what is happening to the patient's mental state? Research shows septic and hemodynamically unstable patients are prone to developing dementia, also known as ICU psychosis. Traditional ICU treatments: heavy sedation, ventilation and bed rest, are related to exacerbated dementia and increased length of stay.
In February 2012, an American Association of Critical Care Nurses (AACN) practice alert called
for implementing early assessment, prevention and detection of delirium and incorporating multiple evidence-based practice strategies into routine daily care. This "ABCDE Bundle", includes Awakening and Breathing trial coordination to assess daily ability to extubate, Careful sedation choice, Delirium monitoring and Early progressive mobility.
The ICU at Chandler Regional Medical Center (CRMC) began introducing practice changes in May 2012 to address these evidence based practice recommendations. Since that time, the unit has assessed patient sedation twice daily utilizing the Richmond Agitation Sedation Score (RASS), started CAM-ICU delirium assessment each shift, initiated daily multidisciplinary "walking rounds" on morning and night shift, developed and implemented a standard ventilation liberation protocol. Minimal sedation, opportunities for patients to cooperate in self-care, and daily trials for extubation have become the routine in the CRMC ICU. We identify dementia in early stages and treat it if necessary. We discourage heavy sedation, not only because of the risk of increased dementia with sedation, but because improved patient awareness while managing pain allows the patient to become more involved in his/her recovery.
Patient sedation levels have improved; currently, 99% of patients have an appropriate sedation scale level at time of ventilation weaning. CRMC patients are experiencing a decrease in average patient days on the ventilator from 3.6 in April 2012 to 2.92 in December 2012 with zero ventilator assisted pneumonias (VAP) in the last quarter of 2012. These results support the implementation of the ABCDE Bundle in the ICU to improve patient outcomes.
American Association of Critical Care Nurses (2011). Delirium Assessment and Management [Practice Alert]. Retrieved from http://www.aacn.org/WD/ practice/docs/practicealerts/delirium-practice-alert2011.pdf.
Jacobi, J, Fraser, GL, & Coursin, DB (2002) Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Critical Care Medicine, 30 (1), 119-141.
Pun, B. T., & Ely, E. W. (2007). The importance of diagnosing and managing ICU delirium. Chest, 732(2), 624-636.
Diana Geraghty BSN, RN, CCRN
Diana Geraghty is the Critical Care Education Specialist at Chandler Regional Medical Center. She has been an ICU nurse for 78 years and is extremely proud of the work her colleagues are doing to promote a positive patient experience in the ICU at Chandler Regional.