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Nurse-led team helps ICU patients at risk of delirium

Wednesday June 6, 2012
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A bundle of practices employed by a nurse-led team of healthcare providers can help ICU patients avoid delirium and weakness, allowing them to heal sooner and remain physically and psychologically healthier after leaving the hospital, according to a study.

The annual cost of caring for delirious patients on ventilators is estimated at between $6.5 billion to $20.4 billion, according to a news release from the Robert Wood Johnson Foundation. The Interdisciplinary Nursing Quality Research Initiative, an RWJF program, funded the study.

An article reporting on the study, which appeared in the April issue of Critical Care Nurse, underscored the central role of the nurse in successfully implementing the bundle. It describes how to implement the bundle and the roles of each member of the team that provides care to patients in the ICU, with particular attention to the nurseís role.

The implementation of these practices was conducted by an interprofessional team led by Michele Balas, RN, PhD, APRN-NP, CCRN, assistant professor at the University of Nebraska Medical Centerís College of Nursing, and William Burke, MD, professor of psychiatry and vice chairman for research at the University of Nebraska Medical Center. They examined a set of evidence-based practices called the Awakening and Breathing Coordination, Delirium Monitoring and Management, and Early Mobility (ABCDE) bundle.

"There are instances of patients who suffered delirium in the ICU experiencing post-traumatic stress disorder after going home," Burke said. "As healthcare providers, we must do everything we can to ensure our patientsí rapid return to health and help them avoid any trauma. This series of practices does that."

The ABCDE bundle uses the best available evidence on delirium, immobility, sedation and analgesia, and ventilator management in the ICU, according to the study. It consists of interventions tested in clinical trials that have been adapted for everyday use in the ICU, and is founded on three primary principles: improving communication among members of the ICU team, standardizing care processes and breaking the cycle of oversedation and prolonged attachment to a ventilator that can lead to delirium and weakness.

The bundle, developed by E. Wesley Ely, MD, MPH, Eduard Vasilevskis, MD, and their colleagues at Vanderbilt University, includes: nurse-implemented, protocol-directed sedation; daily interruption of a patientís infusion of sedatives until the patient can follow simple commands or becomes agitated (spontaneous awakening trials); periodically taking a patient off a ventilator to breathe on his or her own (spontaneous breathing trials); screening patients for delirium using either the Confusion Assessment Method-ICU or the Care Delirium Screening Checklist; and introducing physical and occupational therapy as soon as possible.

"The ABCDE bundle is complex, but it holds great potential for decreasing the time critically-ill patients need to spend on ventilators and in the ICU, and decreasing their recovery time after they leave the hospital," Balas said.

"Because they are the healthcare providers who interact most frequently and for the longest periods of time with patients, nurses are the linchpin in this intervention. They are responsible for the initial assessment of patients Ö and they are the communications link for the healthcare team."

The Interdisciplinary Nursing Quality Research Initiative is funded by the Robert Wood Johnson Foundation. To learn more, visit www.inqri.org or follow on Twitter at @INQRIProgram.

To read the study explaining the implementation of the bundle, visit http://bit.ly/KRjekC.


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