Trinity’s ABCDE’s of Critical Care

In a delicate balance between life and death, ICU teams caring for critically ill or injured patients often find themselves searching for the optimum point between two opposites.

Patients depending on ventilator support for their next breath also face the paradox that the longer the duration and the higher the pressure required, the greater the risk of organ damage and complications like pneumonia that could compromise their chances for survival.

The effects of pain medications and sedatives can make a difficult situation more complex. Although necessary to help patients tolerate treatment and remain still enough for their bodies to heal, these medications depress respiration. They are also linked to ICU-acquired dementia with depression and possible hallucinations that can have long-term psychological effects.

What can break this circle and help patients move out of the ICU to get home faster? Trinity Medical Center is seeing good results from a strategy known as the ABCDE protocol.

“We read about some very positive effects of this evidence-based approach. The objective is to improve outcomes and reduce complications from oversedation and prolonged ventilation,” Trinity Chief Nursing Officer Andy Romine, RN, said. “We implemented the protocol last year, and thus far, we’re seeing some encouraging improvements.”

Sherry Cole, RN, Cardiac Clinical Excellence Coordinator at Trinity, described the protocol and how it is used for patients.

“It’s a bundle of best practices for the ICU that was recently proposed,” Cole said. “The letters are for the steps we follow every day. A is for awakening. Depending on the patient’s diagnosis and condition, when they meet the protocol criteria we reduce their sedation once a day so we can evaluate how they are doing. We time the awakening so we can also evaluate B, or breathing. When patients come around, a respiratory therapist is there to help them see how well they can breathe on their own. If they are showing progress, we may be able to begin weaning them from the ventilator earlier.”

C is for consider. In light of information gathered during the evaluation, is it time to consider adjusting the dosage or the type of sedation patients are receiving? A big part of that consideration is D, checking for delirium. Some medications, particularly benzodiazepines, have been linked to ICU-acquired dementia.

“Some patients can relax while on ventilation, but some have discomfort. It isn’t easy being immobile for so long while fully awake. The emotional trauma of an injury or serious illness can also be distressing,” Cole said. “While patients are awake, we check their mental and emotional status. Depression is common, but more subtle to detect. The hallucinations related to delirium can be terrifying. Some patients think someone is trying to hurt them. It can be so frightening that there have been links to long-term PTSD. We may have to sedate patients to keep them from hurting themselves, but the faster we can reduce their exposure to sedatives, the better their overall condition is likely to be.”

E is for early exercise and mobility as patients are able.

“We first make sure patients are stable, and while they are awake, we begin to see how much they can do. Being immobile on a ventilator can cause rapid deconditioning,” Cole said. “We may start with raising the head of the bed. Then we may move on to grooming and range of motion exercises to see how well they tolerate it. Later they may be able to sit up on the side of the bed, then move to a bedside chair. Eventually, we want to get them ambulatory as they are strong enough.”

Romine said, “The protocol is a collaborative effort. In addition to the ICU nurse, respiratory therapist and the physician, we have physical therapists, occupational therapists and other members of the care team involved as the patient improves.”

Research shows that daily interruption of sedation to follow the ABCDE protocol is reducing complications like pneumonia, shortening ICU stays, and reducing the duration of ventilation and infusion of sedatives. By standardizing care processes, it also seems to enhance the effectiveness of care teams working together.

“There are some exclusion criteria, but we are using the protocol with most ventilator patients,” Romine said. “Every patient is different, of course. The protocol is new, and we’re still evaluating at this point, but we’ve seen dramatic improvements in quality measures in some patients. It looks like this will be one more tool we can use in our continuing effort to improve patient care.”

Cole said, “In the ICU, we work with the sickest of the sick. We want to help them get better as soon as possible by giving them the best possible care. From what I’ve observed, I think this protocol will be the wave of the future. It will be the standard of how care is given.”