In 2013, the Society of Critical Care Medicine (SCCM) recommended the following as basic to ICU patient care: routinely monitor all intensive care unit (ICU) patients for pain, depth of sedation, and delirium, using valid and reliable PAD assessment tools;(2) assess and treat pain first, before sedating patients; (3) avoid deeply sedating patients; (4) use nonpharmacological delirium management strategies over medications to prevent and treat ICU delirium; and (5) link PAD management to ventilator weaning and early mobility efforts.
These recommendations have been incorporated into a single bundle of best practices, known as the ABCDEF bundle:
A - Assess, prevent, and manage pain
B - Both spontaneous awakening and spontaneous breathing trials [SATs/SBTs];
C - Choice of analgesic and sedation
D - Delirium: assess, prevent, and manage
E - Early mobility and exercise
F - Family engagement and empowerment; Integrating pain, sedation, and delirium management
allnurses.com staff recently interviewed Joanna Stollings, PharmD, a clinical pharmacist in the department of pharmaceutical services at Vanderbilt University Medical Center (VUMC), Nashville, Tennessee. Here is what we discussed:
Q: This is a multi-disciplinary assessment. How are institutions initiating this aspect? Daily meetings/huddles or is each discipline responsible for their own part of it?
Institutions are using many different methods to implement the ABCDEF Bundle. One of the best has each of the team members to present a separate component of the bundle during interdisciplinary rounds. Another approach is to include documentation of the entire bundle in one area of the medical record. Our group is actively working with Epic and Cerner to help with this documentation process. We want to avoid having practitioners practicing in silos and to promote the interdisciplinary aspects of this bundle to promote the best care of the patient.
Q: Regarding family engagement in ICU care of their loved one, does the introduction of a formal palliative care program fit into this objective? Does open (24/7) visitation of family members help to achieve family engagement? In many pediatric ICUs, there is open visitation. Could adult ICUs take this as an example?
A formal palliative care program can be part of the objective of family engagement. The Family element of the ABCDEF Bundle promotes involving the family in all decisions about patient care. Adult ICUs definitely could use the open visitation policies that are commonly found in pediatric ICUs. Open visitation by family members definitely helps with family engagement. It allows the family members to be present during interprofessional rounds and to assist in the implementation of other parts of the ABCDEF Bundle such as assistance with physical therapy.
Q: Regarding mobility assessment - does implementing early physical therapy referral assist with this goal?
Implementing a referral for early physical therapy can help with obtaining appropriate mobility assessments. However, nurses, physicians, advanced practice nurses and physician assistants, etc. also need to be able to do an appropriate mobility assessment to better triage the utilization of physical and occupational therapists to the most complicated patients.
Q: With the opioid overuse crisis, utilizing a range for dosing of opioids for pain control is often ordered for ICU patients. Of course, this must be regulated by hospital/facility policy. What educational material would be utilized to provide this education and best practice for the bedside ICU nurse?
We would recommend utilizing resources from the Joint Commission and/or the American Pain Society to educate nurses about range dosing of opioids.
Q: How do you get "buy-in" from the bedside nurse who can already be overwhelmed with documentation and care of the patient?
Seeing their patients have better outcomes and other results from implementing the ABCDEF Bundle help secure buy-in from bedside nurses. While it is important to introduce the concept of the ABCDEF Bundle as a whole when implementing it, the team can focus on the various elements individually over time. This allows the unit to keep the big picture in mind while fine-tuning the details along the way. It always helps the whole team to remember that these elements are interrelated. When ICUs start to use the ABCDEF Bundle, we recommend they start with one letter and to start with only a couple of patients. As nurses start to see the results of each of the different components of the bundle in a few patients, they will want to implement the Bundle in more patients.
Resources Utilized by Joanna Stollings:
Common Challenges to Effective ABCDEF Bundle Implementation: The ICU Liberation Campaign Experience
Implementing the ABCDEF Bundle: Top 8 Questions Asked During the ABCDEF Bundle Improvement Collaboration
AACN news release: Practical Advice for Implementing the ABCDEF Bundle
Society of Critical Care Medicine