Kelly Martin

Background and Definitions

Risks Associated with Prolonged Ventilation
Prolonged ventilation is associated with an increased risk for
VAE Ventilator (Associated Events), increased risk for
pressure ulcers, skin breakdown, and muscle atrophy
related to extended immobility, and increased risk for
delirium.
CDC Guidelines
In 2015 it was found that three ICU patients had a Ventilator
Associated Condition (VAC). The Center for Disease Control
and Prevention has designated three tiers to a Ventilator
Associated Event. 1) Ventilator-Associated Condition (VAC);
2) Infection-related Ventilator-Associated Complication
(IVAC); and 3) Possible VAP (PVAP). The use of this three tier
method expands the surveillance of mechanically ventilated
patients to include additional complications. Most VAEs are
caused by pneumonia, pulmonary edema, atelectasis, or
acute respiratory distress syndrome.
Delirium
Delirium impacts between 60 and 80 percent of
mechanically ventilated patients in the U.S, but in many
patients it goes undiagnosed and untreated. Prevention and
early detection of delirium in ICU patients is key. Delirium
can cause prolonged ventilator days and ICU stay,
increased mortality rates, and increase risk for
neuropsychological disorders such as Post Traumatic Stress
Disorder. Delirium can also affect patients who are not
mechanically ventilated.
Quality Indicators
Ventilator Management Quality indicators are significantly
related to the implementation of or documentation of
sedation vacation, also known as spontaneous awakening
trials. At Adirondack Medical Center ICU, in the first quarter
there were three ventilated patients and 100% compliance.
In the second quarter there was 78% compliance, and
sedation vacation was not implemented on two of the three
eligible ventilated patients. In the third quarter there was
67% compliance, and sedation vacation was not
implemented on one of two eligible ventilated patients.

Purpose
The purpose of this project was to plan a Ventilator
Associated Event protocol in response to the quality
indicators. This policy will include best practices nurse
and respiratory driven spontaneous awakening and
breathing trials. Finally, there is no tool for the
assessment of iatrogenic delirium in the ICU. This tool
will help in the prevention and early detection of ICU
delirium.

Methods and Results

A literature review was completed and researched showed that
an ABCDE bundle injunction with a VAE protocol is best practice.
A nine question survey was administered to the nurses on the
Intensive Care Unit and to the Respiratory Therapy department.
A total of 6 surveys were received on Tuesday Nov 17th out of
possible 20. 4 from the nurses and 2 from the respiratory
therapist. One question asked the participants to review the
attached delirium monitoring tools. 33% said they preferred the
Intensive Care Delirium Screening Checklist Worksheet (ICDSC),
33% said they preferred the Confusion Assessment Method, 33%
reported no answer.
The survey questioned nurses knowledge related to sedation
vacation goals and exclusion criteria. Over 75% of respondents
did not know proper exclusion criteria for implementing a
sedation vacation. Additional teaching is required.
The survey question respiratory therapy knowledge related to
spontaneous breathing trial goals and exclusion criteria. Of the
two respondents adequate responses were given.

Answer

Survey Question

75% - Ramsay Sedation Scale Which sedation scale do you use to

monitor sedation level? (Only nurses)
75% - Richmond Agitation
Scale
66.6% -Routinely
33.3% -Sometimes

How often are sedation goals addressed

in rounds for mechanically ventilated
patients? (Both nurses and Respiratory
Therapy)

66% - None
16% - Dont Know
16% - General Assessment

What delirium assessment tool do you

use? (Both nurses and Respiratory
Therapy)

Delirium Management
Delirium is an acute change in level of consciousness, in
conjunction with inattention, disorientation, hallucination,
psychomotor changes, and inappropriate speech. All of these do
not have to be present for a delirium diagnosis.
Assessment of Delirium:
There are known risk factors associated with acute delirium.
These include pre-existing dementia, hypertension, alcoholism,
and severe admission diagnosis.
A uniform and valid tool should be used daily among ICU
patients. These tools include the Confusion Assessment Method
for the ICU (CAM-ICU) and the Intensive Care Delirium Screening
Checklist (ICDSC). Patients on a ventilator should be assessed for
delirium every 24 hours. Non-ventilator patients should be
assessed for delirium if there is a known mental status change
from baseline.
Therapeutic Management of Delirium:
Stop, Think, and Medicate (if necessary)
- Stop: Is targeted sedation being met? Is patient on any
benzodiazepines?
- Think: Are there any potential causes of delirium present?
Toxic Situation, Hypoxemia, Infection and Immobility, Nonpharmacologic interventions (room with natural lighting,
reorientation, hearing aids in place, adequate sleep schedule), K+
(what are the patients potassium levels)
-Medicate: Haloperidol and atypical antipsychotics
occasionally prescribed for delirium. Primarily want to treat cause
of delirium (for example elderly patients with UTI exhibits delirium
symptoms).

Discussion of ABCDE Bundle

Awakening and Breathing Trial Coordination: Collaborative
approach is necessary when administering sedation (type and
amount), then allowing patient to wake up from sedation safely (key
time fore reorienting patient), and finally assessing the patients
ability to breathe by themselves by safely weaning them from the
ventilator. These trial involve teamwork with physicians, nurses,
respiratory therapists and pharmacists.
Delirium Assessment and Management: Daily monitoring for the
presence of delirium, as well as addressing the presence of pain and
agitation.
Early Progressive Mobility: Collaboration among the ICU staff and
the Physical Therapy team is necessary. Mobility goals for patient
must be assessed with safety of the patient as primary importance.
Mobility of the patient should go from passive range of motion, to
active range of motion, and eventually to ambulation of the patient.

Conclusion
In conjunction with the VAE protocol, the ABCDE bundle should be
used to prevent delirium in the ICU. Increased staff knowledge
on the signs and symptoms of delirium is imperative for its
prevention and early detection in the ICU. For this bundle to be
effective strong collaboration among interdisciplinary staff, such
as nurses, physicians, respiratory therapy, and pharmacy must
be made. Non-pharmacologic interventions such as reorientation
to person, place, and time and use of natural light (when
possible) should be used among all ICU patients.