HealthCare

The ABCDF Bundle: Transforming ICU Care for Better Outcomes

The ABCDF bundle is a protocol that is based in years of research that has been proven to give patients in the ICU the best chance to survive and thrive. It should be standardized in all ICUs, especially in the United States, as it is considered the gold standard of care. It provides tools that guides clinicians to keep patients as awake, mobile, autonomous, communicative, connected with their families, and strong as possible during critical illness. Each letter of the ABCDF bundle is a tool. A is assess, prevent, and treat pain. B is both spontaneous and awakening trials. C is choice of analgesia and sedation. D is delirium. Assess, prevent, and treat delirium. E is early mobility. F is family engagement. In a large study involving over 15,000 patients with a spectrum of compliance with this protocol, they found incredible results. They saw that the likelihood of dying within seven days decreased by 68%. Patients were 46% less likely to come back to the ICU. Patients were 36% more likely to go home after the hospital rather than to a care facility. Delirium decreased by 25 to 50%. So this protocol is your loved one's best chance to receive the most humane and effective care possible. Feel free to ask your care team how you can help optimize the ABCDF bundle in their care. Click the link below to learn more.

The ABCDF bundle is a protocol that provides the best chance for ICU patients to survive and thrive. It consists of tools such as assessing, preventing, and treating pain; spontaneous and awakening trials; choice of analgesia and sedation; delirium assessments, prevention, and treatment; early mobility; and family engagement. A study involving over 15,000 patients showed incredible results with this protocol, resulting in decreased likelihood of dying within seven days, better chances of not returning to the ICU, increased chances of going home after hospitalization rather than to a care facility, and decreased delirium by 25 to 50%.

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The ABCDF bundle is a research-based protocol that aims to optimize care for patients in the ICU. It is considered the gold standard and should be implemented in all ICUs, particularly in the United States. The bundle consists of tools that guide clinicians in keeping patients awake, mobile, autonomous, communicative, connected with their families, and strong during critical illness.

Each letter of the ABCDF bundle represents a tool:
- A: Assess, prevent, and treat pain
- B: Spontaneous awakening trials and breathing trials
- C: Choice of analgesia and sedation
- D: Delirium assessment, prevention, and treatment
- E: Early mobility
- F: Family engagement

In a study involving 15,000 patients with varying levels of compliance with this protocol, remarkable results were observed. The likelihood of dying within seven days decreased by 68%, ICU readmissions decreased by 46%, and patients were 36% more likely to be discharged home instead of to a care facility. Delirium rates also decreased significantly.

Implementing the ABCDF bundle ensures that your loved ones receive the most effective and compassionate care possible. Feel free to discuss with your care team how you can support the optimization of this protocol. For more information, click the link below.

What are the risks of medically-induced comas?

The Hidden Risks of Medically-Induced Comas Revealed

Listen, medically induced comas can be unavoidable for certain patients in the ICU, but for many to most patients that are intubated on ventilators for various reasons, they can and should be awake and mobile because medically induced comas can be dangerous. They increase the risks of dying in and after the ICU, bed sores, infections. They have a massive loss of muscle mass, which can lead them to later need a tracheostomy and days to weeks longer on the ventilator, extensive rehabilitation, relearning how to sit, stand, walk, swallow. They also have this brain disruption from the sedation that can cause ICU delirium, which is sometimes called acute brain failure. This disruption, this damage that's happening to the brain can cause patients to hallucinate and have traumatizing and graphic vivid realities that lead to a post ICU PTSD. They also can develop a post ICU dementia where they have long term cognitive impairments. So all of this can cause permanent physical, cognitive and psychological impairments and disabilities. This can lead to a loss of career changes and family dynamics and relationships. So medically induced comas can change your survival, but also your quality of life. Before we start them, we need to ask, is there an actual need for them? Click the link below to learn more.

Medically induced comas can be dangerous and lead to physical, cognitive and psychological impairments. Before starting one, it's important to ask if there is an actual need for it.

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Medically induced comas can pose significant risks for patients. While they may be necessary for certain individuals in the ICU, many patients who are intubated on ventilators should ideally be awake and mobile. Medically induced comas increase the chances of ICU and post-ICU mortality, as well as complications such as bed sores and infections. They can result in severe muscle loss, potentially leading to the need for a tracheostomy and longer ventilator support, extensive rehabilitation, and relearning basic physical functions. Sedation-related brain disruption can cause ICU delirium, which is often referred to as acute brain failure. This brain damage can lead to hallucinations and traumatic experiences that may contribute to post-ICU PTSD. Some patients may also develop post-ICU dementia with long-term cognitive impairments. These consequences can result in permanent physical, cognitive, and psychological disabilities that impact one's quality of life. It is important to carefully assess if a medically induced coma is truly necessary before proceeding with such treatment.

What role do patients and their families play in the decision-making process when it comes to medically-induced comas?

Empowering Families: The Key Role in Medically-Induced Coma Decision-Making

So we have to understand that in most ICUs there is no discussion as to whether or not sedation is necessary or not after intubation. It is an assumption that any patient that needs to be intubated is going to be sedated and usually deeply sedated throughout their entire time in the ventilator. What should be happening is that there should be a true informed consent during or shortly after intubation with the family and or the patient depending on those circumstances. Care teams should be telling families and or the patients if you want to be sedated there is a risk of delirium which will double your chances of dying in the hospital, increase your chances of long-term cognitive impairments by a hundred and twenty times, increases your risk of psychological trauma, increased risk of infection, those kind of things should be disclosed to the patient and or the family and there should be a discussion as to whether or not there is an actual need for sedation. If there is not then the family needs to be part of that discussion as to whether or not to start sedation or continue sedation and families have a right to bring up these concerns to the care team and say hey I'm worried about these studies, this information, the evidence that shows that this is likely not necessary and or this is very harmful and lethal to my loved one. Families can be part of the discussion as to okay your loved one is agitated, anxious, confused. The families can be a big key player and helping keep the lines and the tubes safe during that hospitalization. If it was my husband in the ICU I would say I will stay here, I will hold his hands, he will not pull out his lines and tubes, please protect his brain, please give him the best chance to survive, I will help your team succeed in bringing the best care to my loved one.

In most ICUs, it is assumed that any patient that needs to be intubated will be sedated. Care teams should have a discussion with the family and/or patient about the risks of sedation, and families should be part of the decision-making process to ensure their loved one's safety.

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In most ICUs, there is often an assumption that sedation is necessary for patients who require intubation and will remain deeply sedated throughout their time on the ventilator. However, it is crucial that there is a true informed consent process with the family and/or patient during or shortly after intubation. Care teams should disclose the risks associated with sedation, such as increased chances of delirium, higher mortality rates, long-term cognitive impairments, psychological trauma, and infection. This discussion should involve both the patient and the family to determine if sedation is truly necessary. If not, families have the right to express their concerns to the care team based on existing studies and evidence that suggest sedation may not be necessary or could be harmful. Families can also play a significant role in assisting with their loved one's care by helping keep lines and tubes secure, especially if the patient becomes agitated or confused. They can advocate for their loved one's brain protection and work collaboratively with the care team to ensure the best possible outcome.

What should family members be aware of when visiting an ICU patient?

Empower Your Role: Key Takeaways for ICU Visits

Families in the ICU should be aware that 1. They are an essential part of their loved one's chances of surviving and thriving during and after the ICU. 2. They can and should ask questions. And 3. In many of our ICUs, we have very outdated beliefs and treatments in regards to sedation and how we care for patients on mechanical ventilation. Many clinicians still believe that every patient that is intubated on a ventilator must be sedated and cannot mobilize. And this is very dangerous and even lethal. So loved ones should ask 1. Does my patient have an indication for sedation? Is there a reason they're sedated? And 2. Is there a reason they can't be mobilized? And 3. Are we preventing, assessing for, and treating ICU delirium? And 4. When and how can we get sedation off and get my loved one up and moving? You can greatly impact the course and the outcomes of your loved one's ICU stay by understanding that you are part of the team, that there are things that we can improve on the ICU, and you can be an active part of improving those things for your loved one.

ICU families should be aware that they are an essential part of their loved one's chances of survival, and they can ask questions such as if there is a reason for sedation, why they can't be mobilized, and if delirium is being prevented, assessed and treated. They can also be active participants in improving the outcomes of their loved one's ICU stay.

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When visiting an ICU patient, family members should be aware of the following: 
1. They play a crucial role in their loved one's chances of survival and recovery during and after the ICU.
2. They have the right to ask questions and seek clarification about their loved one's care.
3. In many ICUs, outdated beliefs and treatments regarding sedation and mechanical ventilation persist. It is important for families to inquire about sedation indications and whether mobilization is possible.
4. Families should inquire about prevention, assessment, and treatment of ICU delirium.
5. Understanding when and how to reduce sedation and encourage mobility can significantly impact the patient's ICU journey.
By recognizing their role as part of the caregiving team, addressing areas for improvement in ICU care, and actively advocating for their loved one's well-being, family members can have a positive impact on the course and outcomes of their loved one's ICU stay.

Can you explain how each letter in the ABCDEF bundle is implemented in ICU care for patients?

Unlocking the ABCDEF Bundle: Transforming ICU Care

The ABCDF bundle is a compilation of tools that guides how we care for patients in the ICU, especially those on mechanical ventilation. Each letter represents a specific tool. So A is for assess, prevent and treat pain. This means that we're constantly evaluating whether or not patients have pain. And I would suggest that this is best done when patients can tell us what they're experiencing, what they need and what helps. B is for both spontaneous awakening and breathing trials. This means that we are turning sedation down or off when there is no longer an indication for sedation. And the breathing trials are when we adjust certain settings on the ventilator, allow patients to take their own breaths to see if they're ready to be without the ventilator support. C is choice of analgesia or sedation. This means that after each intubation, we are asking, is there an indication for sedation? And if there is, then we will give the safest sedative with the lowest dose for the shortest duration possible. We'll also make sure that we are using analgesia or pain management before starting sedation and then seeing if sedation is needed on top of that. D is delirium, prevent, assess and treat delirium. This means that we're using the CAM screening tool to make sure we're identifying delirium early on. And we are also providing a process of care in which we're preventing delirium from happening. This means that we're avoiding delirogenic medications. We're providing early mobility, family engagement, real sleep at night. And this leads us to the E, which is early on mobility. This means that patients are doing their highest baseline functional level promptly on unless there's a contraindication. And F is family engagement. This means that there are no family restrictions. Families are part of the ICU team and engaged throughout the process of care. This is how we give patients the best chance to survive and thrive during and after the ICU.

The ABCDF bundle is a collection of tools that help guide how we care for patients in the ICU, especially those on mechanical ventilation. A stands for assess, prevent and treat pain, B is for spontaneous awakening and breathing trials, C is for choice of analgesia or sedation, D is delirium, prevent, assess and treat delirium, E is early mobility and F is family engagement.

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The ABCDF bundle in ICU care for patients, especially those on mechanical ventilation, consists of specific tools implemented to guide their care. Each letter represents a different tool. 

A stands for assess, prevent, and treat pain. Constant evaluation of patients' pain levels is essential, particularly when they can communicate their experiences and needs effectively.

B represents both spontaneous awakening and breathing trials. Sedation is reduced or turned off when it's no longer necessary, and breathing trials are conducted to determine if patients are ready to be weaned off ventilator support.

C indicates the choice of analgesia or sedation. After intubation, the need for sedation is evaluated. The goal is to provide the safest sedative at the lowest dose and for the shortest possible duration. Analgesia or pain management is also administered as needed before considering sedation.

D focuses on delirium prevention, assessment, and treatment. The CAM screening tool is used to identify delirium early on. Various strategies are employed to prevent delirium, such as avoiding medications that may cause it and promoting elements like early mobility, family engagement, and proper sleep.

E emphasizes early mobility, ensuring that patients promptly engage in activities matching their highest functional level unless there are contraindications.

F highlights family engagement as an integral part of the ICU team throughout the care process. There are no restrictions on family involvement.

Implementing these tools gives patients the best chance of survival and recovery during and after their ICU stay.

Why won’t my loved one wake up from the medically-induced coma now that sedation is off?

Why won't loved ones wake up from medically-induced comas? The surprising reasons revealed.

There are a number of potential reasons why patients do not wake up after medically induced comas. Some of the less common reasons, but still viable reasons are potential strokes, brain bleeds, things like that, that could have occurred without being detected while patients were sedated. Another reason, more commonly, can be that sedation has accumulated in the body. When we have injured kidneys or livers, that sedation doesn't metabolize out of the body at a normal rate. Also, certain sedatives like propofol accumulate in the fat tissue. And so even when sedation has been turned off, there can still be a high level of sedation in the body causing patients to continue to be sedated. And that can take hours to days to weeks to really clear out. Another top reason for patients not waking up after sedation is turned off is because of hypoactive delirium, in which sedation has disrupted the brain so severely that it is not able to be aroused, not able to wake up. And so that can take again, hours to days to weeks for that brain to heal, recalibrate, and then reconnect with reality and with their environment.

Patients do not wake up after medically induced comas for a number of reasons, such as strokes, brain bleeds, accumulation of sedation in the body due to kidney or liver problems, and hypoactive delirium.

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There are various reasons why a loved one may not wake up after the sedation is discontinued in a medically-induced coma. Some less common but possible reasons include undetected strokes or brain bleeds that may have occurred during sedation. A more common reason is the accumulation of sedation in the body. In cases where there are kidney or liver injuries, sedation may not be metabolized at a normal rate. Additionally, certain sedatives can accumulate in fat tissue, resulting in persistent sedation even after the medication is stopped. It can take hours, days, or even weeks for the body to fully clear out the accumulated sedation. Another common reason for delayed awakening is hypoactive delirium, where the disrupted brain is unable to be aroused or wake up. The healing and recalibration of the brain can take time, ranging from hours to days or weeks before reconnecting with reality and their environment.

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Kali is a nurse practitioner that specializes in sedation and mobility practices in the ICU. 

She is the host of 2 podcasts: 
“Walking Home From the ICU” is dedicated to helping ICU clinicians understand patient perspective and current research around medically-induced comas. 

“Walking You Through the ICU” provides information, perspective and tools to help loved ones of ICU patients advocate for practices for the best chance to survive and thrive. 

Kali trains ICU teams to become “Awake and Walking ICUs” through current research and humane treatments. She supports patient advocates to help ICU teams the ABCDEF Bundle in their loved one’s care in the ICU.

Neither AnyQuestion nor its Experts provide medical advice, diagnosis or treatment or otherwise provide professional healthcare services.

Kali Dayton,DNP,AGACNP