Reducing iatrogenic risks: ICU-acquired delirium and weakness--crossing the quality chasm

Abstract

ICUs are experiencing an epidemic of patients with acute brain dysfunction (delirium) and weakness, both associated with increased mortality and long-term disability. These conditions are commonly acquired in the ICU and are often initiated or exacerbated by sedation and ventilation decisions and management. Despite > 10 years of evidence revealing the hazards of delirium, the quality chasm between current and ideal processes of care continues to exist. Monitoring of delirium and sedation levels remains inconsistent. In addition, sedation, ventilation, and physical therapy practices proven successful at reducing the frequency and severity of adverse outcomes are not routinely practiced. In this article, we advocate for the adoption and implementation of a standard bundle of ICU measures with great potential to reduce the burden of ICU-acquired delirium and weakness. Individual components of this bundle are evidence based and can help standardize communication, improve interdisciplinary care, reduce mortality, and improve cognitive and functional outcomes. We refer to this as the "ABCDE bundle," for awakening and breathing coordination, delirium monitoring, and exercise/early mobility. This evidence-based bundle of practices will build a bridge across the current quality chasm from the "front end" to the "back end" of critical care and toward improved cognitive and functional outcomes for ICU survivors.

Figures

Figure 1.

Relationship between ICU-acquired delirium and weakness in a patient with sepsis.

Figure 2.

ABCDE is an ICU-acquired delirium and weakness mitigation strategy. This strategy is a protocolized bundle performed daily on mechanically ventilated and/or sedated patients in the ICU. This strategy is interdisciplinary by design and most effective when implemented by nursing, respiratory therapy, and physical therapy personnel working together as an ICU team. ABCDE = awakening and breathing coordination, delirium monitoring, and exercise/early mobility.

Figure 3.

A, Data from Pandharipande et al indicate that lorazepam dose in the preceding 24 h is an independent predictor for transitioning to delirium in the ICU. The effect rapidly increased up to doses of 20 mg/d, at which point the effect plateaued at near 100% probability of transition to delirium. B, Data from Pandharipande et al demonstrate that in both surgical and trauma ICU patients, users of midazolam have statistically increased number of days of delirium.

Figure 4.

One-year survival analysis of the Awakening and Breathing Controlled Trial from Girard et al. Survival was 14% higher at 1 year among the intervention group (spontaneous awakening trial coordinated with spontaneous breathing trial) vs the control group (usual care plus spontaneous breathing trial). SAT = spontaneous awakening trial; SBT = spontaneous breathing trial.

Figure 5.

CAM-ICU. Available at www.icudelirium.org. This stepwise approach integrates information from the any sedation scale into the delirium assessment. CAM-ICU = confusion assessment method for the ICU,; RASS = Richmond Agitation-Sedation Score. Republished with permission from the American Medical Association.