MA Vogelsong, J Henry, M Lough, K Merriman, M Young, A Rogers, J Lorenzo

Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA

IMPLEMENTING AN AWAKENING, BREATHING, DELIRIUM SCREENING, AND

MOBILITY PROGRAM FOR MECHANICALLY VENTILATED PATIENTS

Survivors of critical illness experience high rates of physical, cognitive,

and emotional impairments.1,2

• Can last months to years post-discharge.3,4

Sedation minimization, spontaneous breathing trials, delirium screening &

management, and early mobilization can combat these effects.5,6

Use of endotracheal tubes with subglottic suction ports (“subG ETTs”) and

elevating patients’ head of bed ≥30° can ↓ rates of ventilator-associated

events.7

Bundled approaches have been reported to ↓ duration of mechanical

ventilation, ↓ delirium, ↓ ICU length of stay, and ↓ mortality without ↑ in

adverse effects.8,9

BACKGROUND

To increase performance of 6 daily process measures in two medical-

surgical ICUs by the end of the 18 month implementation period:

1. Spontaneous awakening trials (SATs) by 20%

2. Spontaneous breathing trials (SBTs) by 20%

3. Delirium screening via CAM-ICU to >90%

4. Mobilization by 20%

5. Use of subG ETTs to >70%

6. Head of bed ≥30° compliance to >90%

METHODS

AIM

Multidisciplinary involvement of all stakeholders is key to obtaining buy-in.

Changes take time, especially with more complex interventions (e.g.

SAT/SBTs, early mobility as compared to delirium screening, use of subG

ETTs, HOB ≥30°).

EMR can be leveraged to streamline workflow and enhance change.

Coordination amongst many teams is critical. e.g. Increase in performance of SAT/SBTs, but still delay to extubation after

successful SBT overnight residents often uncomfortable extubating patients,

but staffing limitations impede performance during day shift.

LESSONS LEARNED Ongoing assessment of process measures, including efforts to maintain

sustainability and further increase performance.

Addition of assessment of effects on patient outcomes, ultimately hoping

to show meaningful improvements.

NEXT STEPS

Process Measure Baseline Changes Made

SAT No formal protocol.

Perception that patients over-

sedated.

• Formal safety screen developed, RN to perform.

• Formal workflow developed linking SAT & SBT.

• Protocol printed on placards & posted throughout unit.

• “Opt out” of RN/RT-driven protocol with ventilation order

set.

• EMR flowsheet created to streamline charting. SBT No formal protocol.

Long delay b/w successful SBT &

extubation.

Delirium screening Not formally assessed. • Delirium taskforce created.

• Disseminated CAM/RASS placards & education to RNs,

housestaff.

• Modified EMR to make target & actual RASS readily

visible to RN, MD.

• Revised EMR order sets to remove redundant/conflicting

target RASS orders; default order = target RASS -1 to 0.

Early mobility Driven mainly by PT consult.

No formal protocol.

• Full-time PT & rehab aid dedicated to ICUs.

• Acquired new equipment.

• Space analysis in patient rooms removed unnecessary

equipment, organized remaining equipment.

• Changed default activity order in admission order set from

“bedrest” to “activity ad lib.”

Subglottic ETT Not routinely used.

Equipment not readily available.

• Acquired new subG ETTs, suction equipment.

• Stocked ED, anesthesia airway boxes, code carts, &

certain OR cases (CT surgery, liver transplant) with subG

ETTs.

Head of bed ≥30° Routinely performed unless

contraindicated.

• Maintained recommended practice w/ angle indicator on

hospital beds.

Run Charts. Percent of patient-days with each daily process measure performed based on intermittent 7-day rolling audits by

trained personnel.

OUTCOMES

Figure 3. Placards posted throughout unit and

on ventilators detailing new formal SAT & SBT

protocol.

Overall Process • Multidisciplinary group (administrators, MDs, RNs, RTs, PTs) met monthly to guide project

& disseminated information to their respective groups.

• Collected & reviewed baseline data.

• Brainstormed potential barriers & possible interventions.

• Conducted repeated educational sessions w/ providers.

• Conducted rolling audits throughout implementation period for review and adaptation of

interventions.

• Coordinated with overseeing entity (CUSP4MVP Program w/ Johns Hopkins University).

REFERENCES 1. Stevens RD et al. Neuromuscular dysfunction acquired in critical illness: a systematic review. Intensive Care Med. 2007;33(11):1876-1891.

2. Shehabi Y et al. Delirium duration and mortality in lightly sedated, mechanically ventilated intensive care patients. Crit Care Med. 2010;38(12):2311-2318.

3. Pandharipande PP et al. Long-term cognitive impairment after critical illness. NEJM. 2013;369(1):1306-1316.

4. Herridge MS et al. for the CCCTG. Functional disability 5 years after Acute Respiratory Distress Syndrome. N Engl J Med. 2011;364(14):1293-1304.

5. Schweickert WD et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet.

2009;373(9678):1874-1882.

6. Girard TD et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and

Breathing Controlled trial): a randomised controlled trial. Lancet. 2008;371(9607):126-134.

7. Damas P et al. Prevention of ventilator-associated pneumonia and ventilator-associated conditions: A randomized controlled trial with subglottic secretion

suctioning. Crit Care Med. 2015;3(1):22-30.

8. Balas MC et al. Effectiveness and Safety of the Awakening and Breathing Coordination, Delirium Monitoring/Management, and Early Exercise/Mobility Bundle.

Crit Care Med. 2014;(c):1-13.

9. Barnes-Daly MA et al. Improving hospital survival and reducing brain dysfunction at seven California community hospitals: Implementing PAD guidelines via the

ABCDEF bundle in 6,06 patients. Crit Care Med. 2017;5(2):171-178.

Barriers to

implementing

ABCDE

bundle

Materials Environment Personnel

Culture Patient Status

- Competing priorities

w/ multiple projects

- Lack IT support

- Lack of institutional

support

- Lack admin support

- Pts too unstable

- Changes in pt status

detract from time to

do ABCDE - Perception as “more

work”

- Reluctance to change

standard practice

- Overcoming “old

school” ideas

- Oversedating pts

- Belief that pts

should “rest” at night

- New policies not easily

accessible to staff

- Lack of time to

complete components

- Inaccurate

documentation in EMR

-Time consuming to input

data on multiple pages in

EMR

- Inconsistent interpretation

of RASS/CAM/safety

screens

- Early AM SAT/SBT may

delay extubation, tire pts,

increase delirium

- No protocols in

place

- “Bedrest” = default

activity order in admission

order sets

- Lack of awareness of

benefit

- High staff turnover (RNs,

residents, etc)

- Shared ownership = lack

of ownership?

- Lack of communication

across providers

- Short-staffed - No “enforcer”

- Requires

multidisciplinary buy-in

- Staff not updated on

project

- Difficult for residents to

make decisions (esp

overnight)

- Attending MDs

disagree w/ protocols

- MDs override SAT/SBT

protocol

- PT equipment not

readily available

- Lack room to

store/use PT

equipment

- Charting cumbersome

- OR, ED, code carts

don’t have subG ETTs

- Pt refuses

- Need new subG

ETTs, suction

- Lack of time, logistics

to educate staff

- Anesthesiologists not

familiar w/ new ETTs

- Fear of harming pt

- Limited weekend

coverage

Methods

Figure 1. Ishikawa diagram of predicted barriers to

implementation.

Figure 2. Pareto chart of commonly perceived

barriers to mobilization at baseline.

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

100%

Perceived Barriers to Mobilization

• Achieved implementation goals for all 6

daily process measures.

• Potential issue of sustainability with

SBTs.

• 3 adverse events (out of 1,783 patient-

days with mobilization) reported over

implementation period.

• Still significant room to improve

(especially SATs, SBTs, mobility).

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

100%

Jan

'15

Feb

'15

Mar

'15

Ap

r '1

5

May

'15

Jun

'15

Jul '

15

Au

g '1

5

Sep

'15

Oct

'15

No

v '1

5

Dec

'15

Jan

'16

Feb

'16

Mar

'16

Ap

r '1

6

May

'16

Jun

'16

Jul '

16

Au

g '1

6

Sep

t '1

6

SATs SAT Baseline Median ↑ 20% Goal

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

100%

Jan

'15

Feb

'15

Mar

'15

Ap

r '1

5

May

'15

Jun

'15

Jul '

15

Au

g '1

5

Sep

'15

Oct

'15

No

v '1

5

Dec

'15

Jan

'16

Feb

'16

Mar

'16

Ap

r '1

6

May

'16

Jun

'16

Jul '

16

Au

g '1

6

Sep

t '1

6

SBTs SBT Baseline Median ↑ 20% Goal

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

100%

Jan

'15

Feb

'15

Mar

'15

Ap

r '1

5

May

'15

Jun

'15

Jul '

15

Au

g '1

5

Sep

'15

Oct

'15

No

v '1

5

Dec

'15

Jan

'16

Feb

'16

Mar

'16

Ap

r '1

6

May

'16

Jun

'16

Jul '

16

Au

g '1

6

Sep

t '1

6

Delirium Screening Delirium screening Baseline Median 90% Goal

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

100%

Jan

'15

Feb

'15

Mar

'15

Ap

r '1

5

May

'15

Jun

'15

Jul '

15

Au

g '1

5

Sep

'15

Oct

'15

No

v '1

5

Dec

'15

Jan

'16

Feb

'16

Mar

'16

Ap

r '1

6

May

'16

Jun

'16

Jul '

16

Au

g '1

6

Sep

t '1

6

Mobilization (Any) Pts days mobilized Baseline Median ↑ 20% Goal

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

100%

Jan

'15

Feb

'15

Mar

'15

Ap

r '1

5

May

'15

Jun

'15

Jul '

15

Au

g '1

5

Sep

'15

Oct

'15

No

v '1

5

Dec

'15

Jan

'16

Feb

'16

Mar

'16

Ap

r '1

6

May

'16

Jun

'16

Jul '

16

Au

g '1

6

Sep

t '1

6

Use of Subglottic Suction ETTs SubG ETT Baseline Median 70% Goal

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

100%

Jan

'15

Feb

'15

Mar

'15

Ap

r '1

5

May

'15

Jun

'15

Jul '

15

Au

g '1

5

Sep

'15

Oct

'15

No

v '1

5

Dec

'15

Jan

'16

Feb

'16

Mar

'16

Ap

r '1

6

May

'16

Jun

'16

Jul '

16

Au

g '1

6

Sep

t '1

6

Head of Bed Elevated ≥30° Elevated HOB Baseline Median 90% Goal

= baseline data collection period

Design: Prospective quality improvement project in two adult medical-surgical ICUs at a academic hospital from 1/1/15-10/31/16.

Mobility equipment acquired

Balance measure: adverse events during patient mobilization.

Ultimately, we hope to improve patient outcomes including duration of

mechanical ventilation, delirium, ventilator-associated events, ICU &

hospital length of stay and mortality.

Laminated placards (Fig. 3) distributed

Laminated placards (Fig. 3) distributed

New SAT/SBT protocol approved

New SAT/SBT protocol approved

Target RASS in RN flowsheet

New RN flowsheet in EMR New RN flowsheet in EMR

Neuro criteria removed from SBT screen

Target/actual RASS, CAM added to rounding sheet

PT/OT order added to rounding sheet

Default activity order changed to “Activity ad lib”

New suction regulators acquired

SubG ETT protocol written

SubG ETTs stocked in code carts, ED, OR

CAM/RASS placards, RN & MD education

New MD order set RASS visible in MD flowsheet

Nursing in-services; rehab aides hired