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Why ICU Patient Outcomes Must Go Beyond Survival

Improving ICU patient outcomes cannot stop at survival.

Every ICU team understands the urgency of keeping a patient alive, whether they’re suffering from shock, respiratory failure, sepsis, trauma, surgery, or multi-organ failure.

But survival alone does not tell the whole story.

A patient can survive the ICU and still leave with serious weakness, delirium-related trauma, cognitive changes, loss of independence, anxiety, depression, or a need for long-term facility care.

Families often understand this quickly. They’re grateful their loved one survived, but they also start asking questions, like:

Can they walk?

Can they go home?

Can they think clearly?

Will they remember what happened?

Will they ever get back to the life they had before?

And these questions should matter inside the ICU, not only after discharge.

In any case, if ICU teams want to improve patient outcomes in a meaningful way, they need to look beyond mortality and ask what kind of survival their practices are helping create.

ICU Patient Outcomes Should Include More Than Mortality

Mortality will always remain one of the most important ICU outcomes, as it’s measurable, high-stakes, and deeply meaningful.

But mortality is only one part of the outcome picture.

Strong ICU patient outcomes should also include physical function, cognitive function, delirium burden, time on mechanical ventilation, discharge destination, ability to return closer to baseline function, psychological recovery, and family experience.

These outcomes are not soft measures, and they play a major role in shaping the patient’s life after survival.

What’s more, they also affect ICU workload, bed flow, discharge planning, long-term health-care costs, and family strain.

When teams only measure whether the patient lived, they can miss the preventable harm that follows the patient long after the ICU team has moved on to the next crisis.

To be clear, I’m not trying to say that ICU teams are ignoring these outcomes on purpose.

All ICU teams want better outcomes for their patients, but the challenge is that long-standing ICU practices, especially around sedation and immobility, can make those outcomes harder to achieve, and make them seem less meaningful.

Functional Recovery Starts in the ICU

Many ICU survivors struggle with weakness that affects every part of their daily lives.

They may not be able to stand without help, need assistance with basic activities, or leave the hospital unable to walk independently, even if they could before they were admitted.

But this loss of function is not always an unavoidable result of critical illness. Sedation and immobility, along with prolonged bed rest can contribute to ICU-acquired weakness and delayed recovery.

And that’s why early mobility matters.

A randomized controlled trial of mechanically ventilated ICU patients combined daily interruption of sedation with physical and occupational therapy in the earliest days of critical illness.

Patients who received early physical and occupational therapy were more likely to return to independent functional status at hospital discharge than those who received standard care.

That is a major outcome because it means the question isn’t only, “Did this patient survive mechanical ventilation?”

The question also becomes, “Did this patient leave the hospital with enough function preserved to go back to the way they were living before they were hospitalized?”

At this point, it’s important for me to point out that early mobility doesn’t mean forcing unsafe activity. It means assessing eligibility, coordinating across disciplines, and helping patients participate in appropriate movement as early as possible.

For some patients, that may mean sitting on the edge of the bed. For others, it may mean standing, transferring to a chair, marching in place, or even walking laps around the ICU.

The trick is knowing who can move, when they can move, how they should move, and how to support them safely.

Cognitive Recovery Also Matters

Families often expect weakness after critical illness, but they may not expect long-term cognitive changes.

However, many ICU survivors struggle with memory, attention, concentration, processing speed, and executive function after discharge. These changes can affect things like medication management, finances, work, relationships, driving, and independence.

Unfortunately, cognitive outcomes can remain invisible to ICU teams because the full impact often appears after the patient leaves the unit. But that doesn’t mean ICU practices have no role in maintaining cognition.

Delirium, deep sedation, sleep disruption, immobility, and lack of engagement can all affect the brain during critical illness.

One randomized controlled trial found that early mobilization reduced long-term cognitive impairment in ICU survivors after mechanical ventilation.

At one year, cognitive impairment occurred in 24% of patients in the early mobilization group compared with 43% of patients receiving usual care.

That is not a small difference, and it suggests that mobility affects more than muscle, and may also support the brain during and after critical illness.

A patient’s brain is not separate from the rest of their ICU experience, and this is one reason ICU teams need to connect daily care decisions to long-term recovery.

When patients remain deeply sedated, immobilized, disconnected from normal cues, and unable to participate in care, the consequences can last far beyond extubation and discharge.

Discharge Home Is a Meaningful Outcome

Discharge destination tells a story.

A patient who survives the ICU but is discharged to a long-term care facility, rehabilitation center, or skilled nursing facility may face a long and difficult road.

For some patients, that level of support is medically necessary. But when ICU practices can help preserve function and reduce preventable complications, discharge home becomes an important outcome to track.

Going home is not just a location. It can mean the patient preserved enough strength, cognition, and independence to return to a familiar environment. And it can also mean less disruption for families, fewer downstream costs, and a clearer path toward recovery.

For ICU leaders, discharge destination also matters operationally.

If patients survive but leave with greater disability, the health-care system still carries the cost, families still carry the burden, and hospital teams still face delays and complex discharge planning.

With that in mind, improving ICU patient outcomes means thinking about where patients are likely to go after the ICU, not only whether they leave the ICU alive.

ABCDEF Bundle Compliance Gives Teams a Practical Structure

The ABCDEF Bundle gives ICU teams a framework for protecting more than survival.

It brings together pain assessment and management, spontaneous awakening trials, spontaneous breathing trials, thoughtful sedation choices, delirium assessment and management, early mobility, and family engagement.

The bundle is not just a documentation exercise. It’s an interdisciplinary care structure.

It asks your team to coordinate decisions that often happen in silos by asking questions like:

Who is managing pain?

Can we turn sedation off?

Is there an indication for sedation?

How does the patient communicate?

Is the patient ready for a breathing trial?

Can the patient participate in mobility today?

What medications may increase delirium risk?

How can family support orientation, comfort, and engagement?

If the patient is unable to mobilize, should we get them on a verticalization bed?

A randomized control trial looked at ABCDEF Bundle compliance and clinical outcomes in the ICU.

Staff education alone improved bundle compliance from 9% to 16%, and data literacy training increased compliance further to 21%.

Full ABCDEF Bundle compliance was associated with lower likelihood of next-day ICU and hospital mortality, lower likelihood of discharge to a facility other than home, and higher likelihood of next-day extubation.

And that’s important because many ICUs do not struggle from lack of awareness alone.

They know the bundle exists. They may even agree with it.

But the most difficult part is ensuring consistent bedside application.

A recent longitudinal analysis explored ABCDEF Bundle compliance and long-term outcomes over 12 months after discharge. Greater bundle compliance was associated with better functional independence and health-related quality of life at 12 months, though the associations were not consistent across all domains.

And that nuance matters.

The evidence does not suggest that one checklist fixes every long-term outcome. It suggests that compliance, fidelity, interdisciplinary work, and post-discharge recovery all deserve attention.

For ICU teams, that is the practical lesson here.

Better outcomes require more than just knowing the evidence. They require a care culture that can apply it consistently, measure it honestly, and adjust when gaps appear.

Culture Change Determines Whether Evidence Reaches the Bedside

Most ICU teams do not need more pressure. They need support.

Many clinicians already know deep sedation and immobility carry risks.

Moreover, they know delirium can be devastating, they know early mobility can help, and they know how important the ABCDEF Bundle is.

But even after all of this, protocols don’t always change.

Because ICU culture is powerful.

If a team believes intubated patients should automatically be deeply sedated, then sedation becomes the default.

If mobility depends on one passionate physical therapist or one nurse who feels confident, it becomes inconsistent.

If respiratory therapy, nursing, physicians, rehab, and leadership are not aligned, everyone may wait for someone else to take the first step.

And if staff fear falls, line removal, agitation, self-extubation, or workflow disruption, then immobility can feel safer even when it increases other risks.

At any rate, protocols help, but they do not change culture by themselves. Education also helps, but it does not always change behaviour, especially when clinicians find themselves under pressure.

ICU teams need practical support that addresses real bedside barriers.

They need shared criteria, leadership buy-in, and staff who can recognize which patients are eligible for awakening and movement.

What’s more, they need interdisciplinary rounding that includes sedation, breathing, delirium, and mobility goals, and space to ask tough questions without feeling shamed or blamed.

All things considered, an Awake and Walking ICU™ can’t come from one champion trying to convince everyone alone.

It requires a team-wide shift in what your ICU considers normal, safe, and possible.

What ICU Teams Can Start Measuring Differently

What teams measure tells staff what leadership values.

So, if the dashboard focuses only on survival, length of stay, and ventilator days, other outcomes may stay hidden.

ICU leaders who want to improve patient outcomes beyond survival can begin by tracking measures such as:

Ventilator-free days

Discharge destination

ICU-acquired weakness

Sedation depth and duration

Delirium incidence and duration

Family participation in care planning

Return to baseline function at discharge

Patient and family-reported recovery concerns

Staff confidence with awake and mobile ventilated patients

Daily spontaneous awakening and breathing trial completion

The percentage of eligible patients mobilized within the first 72 hours

These measures help teams see whether their care practices support survival alone or survival with better recovery.

And they also help leadership identify barriers and ask more important questions, like:

If eligible patients are not mobilizing, why not?

If families are not involved, what information or structure do they need?

If sedation remains deep without a clear indication, what is driving that decision?

If staff do not feel safe mobilizing ventilated patients, what training, staffing, equipment, or collaboration needs to change?

Better ICU Patient Outcomes Protect the Life Patients Return To

Patients and families rarely describe ICU success in terms of clinical metrics.

They talk about whether their loved one came home, whether they could walk into the house on their own, and if they recognized family members, slept at night, remembered what happened, returned to work, or felt like themselves again.

Those outcomes are deeply human, but they’re also clinically relevant.

Critical care can save a life and still leave room to ask better questions about the life being saved. This includes things like:

Can sedation be reduced?

Can we start mobility sooner?

Can this patient be awake safely?

Can we prevent or shorten delirium?

Can family help with orientation and engagement?

Can the team preserve strength, cognition, dignity, and autonomy while treating critical illness?

The questions about these outcomes aren’t intended to compete with survival.

They’re meant to strengthen it and further improve quality of life for those who survive the ICU.

Your ICU team may understand the evidence, but still struggle to apply the ABCDEF Bundle.

Book a free consultation to explore where your team is getting stuck and what support may help you become an Awake and Walking ICU™.

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Checking the Boxes but Missing the Mark: ICU Rounds

After working in 11 ICUs and training 14 others, I have seen multidisciplinary rounds conducted in many different ways.

And I’ve also witnessed how easy it is to check the boxes but still miss the mark.

Even in teams that are more progressive with the ABCDEF Bundle who “check the boxes” during ICU rounds, the bundle is often approached something like this at best:

“This is a 75-year-old male patient with a history of hypertension and type II diabetes admitted for acute respiratory failure secondary to influenza A. He was intubated four days ago.”

Intensivist: “SAT?”

Nurse: “He failed his SAT and SBT this morning and sedation is back at X.”

Intensivist: “Ok, we’ll try again tomorrow.”

Charge Nurse/Clinical Nurse Specialist: “What is his CAM and RASS?”

Nurse: “RASS is -1 and CAM is positive.”

At this point, everyone shrugs in apathy as if to say, “Yup, he’s confused. So is the rest of the unit. Welcome to the ICU.”

Charge Nurse/Clinical Nurse Specialist: “Mobility?”

Intensivist: “Yeah… we can order PT and OT.”

Meanwhile, the patient is actually at a RASS of -3 or lower and trapped in delirium believing their organs are being harvested.

He tried desperately to say, “Please don’t kill me!” during the awakening trial but sedation was resumed and he was shoved back into the horrors of delirium.

PT and OT receive the consultation order, but their full schedule does not allow them to see the patient until the next day.

The next morning, they review the chart and see a RASS of -1 documented. When they approach the patient, they find they’re actually at a RASS of -4 and unable to participate in therapy.

What’s more, the conversation during rounds is nearly identical to what was discussed the day before.

The ABCDEF Bundle boxes are checked and the ABCDEF Bundle dashboard looks compliant, while patients continue to rapidly lose brain function, muscle mass, chances of survival and/or future quality of life.

Then the patient continues to get weaker and more confused, leading to days, weeks, and even months longer on the ventilator.

The unit may have “Centers of Excellence” and/or “Beacon of Excellence” plaques on the wall, but patients continue to suffer preventable harm and mortality.

Moreover, the extra workload and cost of superficially “checking the boxes” without providing the care is unfathomable and unsustainable in this staffing crisis.

View on YouTube: https://www.youtube.com/embed/iTIkzX2HVEo?si=_q3PWyPrSPObRruP

In such a culture and process of care, this patient who walked into the hospital with pneumonia will be wheeled into a nursing home with an acute or even chronic brain injury and neuromuscular condition from ICU sedation and immobility.

What could have been a few days of mechanical ventilation can easily turn into days or even weeks of ICU care which turns into an incredible burden on acute care staff as they wait for a nursing home room to open up and battle high risks of readmission to the ICU from aspiration, falls, etc.

ICU Rounds in Awake and Walking ICUs

For teams that truly understand the ABCDEF Bundle as a box of tools to keep patients as awake, communicative, autonomous, and mobile as possible, ICU rounds are entirely different.

These kinds of teams focus on providing care that’s catered towards returning the patient to their baseline function and quality of life. They treat fellow humans, not just diagnose.

And these kinds of teams know that:

1) The ABCDEF Bundle is not just about ventilator liberation but about life preservation.

2) Sedation is not an assumed necessity but a high-risk and abnormal intervention that warrants an indication, explanation, and discussion.

3) Mobility must be a prompt and standard life-saving intervention like DVT prophylaxis.

4) Delirium is a life-threatening organ failure that must be prevented and urgently treated.

5) The ABCDEF Bundle is an essential set of protocols that are just as important as deciding which antibiotic or fluid to give.

This leads multidisciplinary rounds to run much differently and for discussions to go more like this:

“This is a _____ year old M/F _____ (one personal detail that reflects who the patient is as a person and one personal detail that reflects their baseline cognitive and physical function) with a history of _________ admitted for _______.”

And if they’re intubated, these are the kinds of questions that will be asked:

What is their current RASS?

How does the patient communicate?

Have they been educated on delirium?

What do they report their pain level as?

If sedation is running, what is the indication for sedation?

What is the patient’s RASS and status (ICP, BP, Sp02, etc.) when sedation is turned off?

If their RASS is >0, what is causing this distress and have we treated the cause? Is family at the bedside?

What is the plan to treat the cause of failure?

Have we done an SBT today?  How did it go?

Does the patient have delirium?

If the SBT failed, why did it fail?

If they did fail their SBT, these are the kinds of follow-up questions they’d ask:

What could be causing this?

What is the plan to treat delirium?

What is the plan for follow-up care?

Have we taught the family about delirium?

How much sleep did they get last night?

If they report that they got poor sleep, then they’ll be asking things like:

What is the plan to improve sleep tonight?

What is their baseline level of mobility?

Is there a contraindication to mobility? If yes, what is it?

If the patient is an HLM 1-4, are they appropriate for verticalization therapy?

What level of mobility did they perform yesterday (tolerance, support needed, duration, etc.)?

Which member(s) of the family are involved and what support do they need?

What is the plan for mobility this shift?

Case Study

Now, let’s apply the ABCDEF Bundle and compare this with the first scenario.

“Roger is a 75-year-old male retired welder who loves to build birdhouses. He has a history of type II diabetes and hypertension. He was admitted for acute respiratory failure secondary to influenza A and intubated four days ago.”

Intensivist: “ABCDEF Bundle?

A) Nurse: “Roger uses a clipboard for communication and reports his pain at two out of 10.

B/C) “He failed his SBT this morning because of low tidal volumes and tachypnea from diaphragm weakness which we’re treating with mobility. We’re keeping him on pressure support and keep trying to wean down the support. His RASS is +1 probably because of his hyperactive delirium. He does not have sedation running nor has an indication for sedation.”

D) “For his delirium, his wife is at the bedside and helping him Zoom call his grandchildren. He got four hours of sleep last night and we’re going to try to get him outside today, have him up in the chair, mobilize him twice during day shift, no naps in the afternoon, and night shift will mobilize him one more time, so he should sleep much better.”

E) “At baseline, he was independent and could walk up and down the stairs in his house. Yesterday, he walked 250 feet twice with a walker and took one break. Today we’re going to see if he can go without a break and get him walking that lap twice during day shift and then once on night shift.”

F) “We’re seeing if his son can come stay with him at night to help with his delirium and give his wife a break. They’re helping keep him engaged and we’re leaving restraints off while they’re in the room as they know to keep his hands busy and away from his lines and tubes.”

Conclusion

This patient in an Awake and Walking ICU has high chances of emerging from delirium very soon and being extubated that evening or the next morning.

He has the best chance possible of walking out of the ICU and discharging home from the hospital to resume his normal life after a few days in the ICU.

This is the difference between only “checking the boxes” versus actually providing the care.

Strategic ICU rounds help guide teams to transform care from treating diagnoses to treating people and giving them back lives that are worth living.

Let’s check the boxes on paper and hit a bullseye in practice.

If this resonates with what you’re seeing in your ICU, I can help.

Book a free consultation today and let’s walk through your current approach to mobility and positioning to identify where small shifts could meaningfully improve patient recovery.

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Raging Tigers and Merciful Angels: The Fight to Humanize Critical Care

Medicine is a field of evolution with a continuous trajectory of exploration, discovery, change, and progress.

And this perpetual pattern has been just as reliable as the predictable resistance that comes with change.

Past Revolutionists Who Fought to Humanize Critical Care

This was demonstrated in the journey of Ignaz Semmelweis (pictured below), a Hungarian physician who, in 1850, proposed that birthing mothers were dying from contaminants carried by physicians from cadavers of study to mothers.

Semmelweis was met with refusal to consider that long-held practices were causing patient harm and death.

As a result, he was removed from his position and was suspected to be driven to “madness” as he toured throughout Europe teaching and begging physicians to wash their hands.

He later died of sepsis in an insane asylum.

Elizabeth Kenny (pictured below) found similar opposition when she proposed that children with polio be treated with massage and movement for affected limbs rather than casts and immobilization.

Instead of eagerly accepting new interventions that would save lives and physical function, physicians were threatened and defensive in response to a female nurses’ disputation of their treatments.

Nonetheless, Kenny remained outspoken in advocating for the treatment she knew was right. She was said to be a “raging tiger and merciful angel.”

Eventually, she left the resistance in Australia and came to the United States to start “Kenny Clinics” to treat polio patients using her unique method.

She personally treated over 7,000 children and influenced the care of many thousands more through education and opposition to standard treatment.

The Revolutionists of Today

Even today, after decades of fighting standardized automatic sedation and immobility for all intubated patients, ICU revolutionists are facing similar barriers.

Despite decades of research revealing the harm of sedation and immobility, and evidence showing the benefits of the ABCDEF Bundle, change has been an ongoing battle.

Still, the research clearly shows that when it’s implemented in the way it was intended, the ABCDEF Bundle decreases hospital costs by 30%, 7-day mortality by 68%, delirium by 50%, and hospital readmissions by 46%, while increasing discharges straight home by 36%.

As was revealed in Episode 197 of my Walking Home From The ICU podcast, clinicians who dare to go against cultural norms to give patients the ability to communicate, be informed and autonomous, and mobilize while intubated, face incredible opposition.

ICU revolutionists are demeaned by superiors, bullied and threatened by colleagues, and some nearly lose their jobs in response to them attempting to challenge the status quo by:

Asking questions about sedation and mobility

Mobilizing patients that are appropriate for mobility

Educating families about delirium, mobility, and post-ICU syndrome

Having patients awake and writing on clipboards against colleagues’ preferences

I invite you to listen to this podcast to hear stories from numerous revolutionists who’ve shared their experiences attempting to humanize critical care by advocating for evidence-based practices.

Below you’ll find a particularly poignant example of this, from an occupational therapist, which I shared in the episode:

“I’m an OT and have been very steadfast in trying to promote change, even if it’s minimal. We must start somewhere. Recently, myself and two PTs were recognized by a trauma surgeon for helping get a patient extubated, whom they were adamant would be trached, PEGed, and sent to LTACH.

“I coordinated the sedation, wean pain, medication, vent, weaning, and family present for two days after being intubated and sedated with no SAT/SBT for five days with a doctor who then held nursing and RT accountable to the plan.

“He sent a very thoughtful email to upper-level management about the efforts that were made, the confidence in pushing normal boundaries, the outstanding impact that it had on patient outcomes and requested consistent presence in our MSICU.

“I was never told about this email from my boss. Instead, myself and the two PTs who helped with this co-treat were pulled into a meeting and reprimanded for going ‘outside our scope of practice,’ not following the chain of command, going to the MD over the RN, telling nursing what to do, not including RT in the session, et cetera, et cetera.

“They told us we are arrogant thinking we know more than anyone else, and that ‘it’s not just about what the research says.’ They said change takes years. They explained that the upper-level management from multiple departments, including themselves, do not understand the ABCDEF Bundle or ‘believe in it.’

“So, we cannot continue in this manner, or no one will want to work with us. Since this meeting, myself and those two PTs have been pulled off the ICU to staff the floors.

“They have placed novice and new grad therapists in the ICU, instead, who are not comfortable with early mobility on critically ill or ventilated patients because they are ‘licensed clinicians and understand what is safe, even if it’s bed level.’

“Those therapists would never have a challenging conversation or push any boundary because they simply are not experienced enough to have it. They do as they’re told by nursing and keep their day moving instead of advocating for the patient and what is right.

“Talk about burnout. I ask myself daily how much longer I’m going to be able to keep up with this. I got a written warning for explaining to a nurse that it was okay for therapy to work with someone on 0.4 of Precedex (they were not even intubated) and educating on sedation use, delirium, and preventing ICU weakness because ‘sedation isn’t my scope of practice’ and if the nurse says ‘no’ I should just write a ‘hold,’ not prove that I’m right.

“I was initially hired because of my ICU experience, and this hospital has just built a critical care tower with 78 beds. I have done countless lunch and learns with the therapy department, created resources, provided one-on-one training for comfortability, developed the therapy ICU competency, and so much more over the last two years.

“There’s no internal drive and no external motivators at this place, and people just simply do not care. There’s no incentive to learn.

“I went into health care to help people. I am now questioning my morals and values at the end of the day instead.”

It is astounding to consider that a clinician who orchestrated teamwork and guided collaboration to implement evidence-based best practices that resulted in a patient being spared a tracheostomy and extensive rehabilitation would be kicked out of the ICU by their leadership.

But this is by no means the only example of this sort of behavior.

In Episode 94 of my Walking Home From The ICU podcast, a nurse from an Awake and Walking ICU, who started working in a new ICU, was yelled at in the hallways in front of her entire team for sitting her intubated patients at the side of the bed and Zoom-calling their families during COVID.

Eventually, they stopped assigning her intubated patients because they didn’t like her having the patients awake and moving.

Another revolutionist received a severe written “counseling” for teaching families about delirium, immobility, sedation, and post-ICU syndrome.

The rest of the team did not want that information to be disclosed to families, as they were upset that families would be aware of the risks of these interventions and preparing for post-ICU life.

She was warned to never broach these topics with families again.

Throughout the years, I have been in contact with over a dozen revolutionists who have either changed hospitals or left critical care medicine entirely due to the moral injury of witnessing preventable patient harm and being restrained from protecting or helping them.

In Episode 166 of Walking Home From The ICU, a pharmacist with 10 years of critical care experience left because the hospital’s chief nursing officer banned her from talking about sedation during rounds, as it was upsetting the nurses to have to discuss RASS levels and awakening trials.

During one of her final shifts, she exclaimed, “We are killing these people!”

She then took her vast knowledge, expertise, and compassion – and left critical care.

In Episode 156, a seasoned acute care nurse entered a new critical care position with knowledge about the ABCDEF Bundle.

During her orientation period, she was repeatedly pulled into her manager’s office for being “unteachable” due to her charting a RASS that was lower than what her preceptor wanted her to chart, turning sedation off for an awakening trial rather than just slightly down, asking about mobility, etc.

After a few months of watching patient harm, she gave up on her dream of working in the ICU once she realized she couldn’t tolerate that level of moral injury.

I am inspired by the brave revolutionists who bring the evidence to their clinical leadership to say, “I am willing and ready to work hard to bring these changes that will save lives, millions of dollars, and fix a lot of the problems our hospital is worried about right now.”

It is demoralizing to hear how many are met with the response, “That’s really nice, but it’s not a priority right now,” or “Things are fine the way they are.”

Some of the most lethal words in medicine are “This is how we’ve always done it.”

Yet, that is the common rebuttal revolutionists receive.

They are seen as “troublemakers,” “delusional,” and “difficult to work with.”

This ignorance, fear, resistance, and hostility is creating toxic work environments and increasing the burnout and burden on our clinicians.

Upon hearing Episode 197, which I referenced above, another revolutionist said, “That episode is making me see red. I am SEETHING. It is the Santa Claus effect; I cannot go back and cannot think of how we would still be breaking our back with total care on sedated patients.”

To the revolutionists out there: Keep going. You are not alone. Every 10% improvement in compliance with the ABCDEF Bundle improves survival by 15%. You are saving lives.

And may we continue to be raging tigers and merciful angels by fighting to give patients the best chance to survive and thrive.

Want to connect with clinicians who are fighting to humanize critical care? Join our monthly meetings for ICU Revolutionists to gain support from fellow clinicians from around the world.

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Why Gradual ABCDEF Bundle Implementation Often Results in a Failure to Launch

“Let’s introduce the bundle gradually. We don’t want to overwhelm anyone. Let’s see what the team is willing to do. We can start with awakening and breathing trials, then tackle the rest once we have those down.”

This kind of conversation has echoed through medical organizations and clinical leadership teams for years.

It’s a logical approach, especially for those who are trying to change their ICU’s culture, and working to prioritize awakening and mobility, rather than just automatically sedating intubated patients.

This type of change must be strategic and safe.

But is ABCDEF Bundle implementation, done “one letter at a time” truly the safest and most effective pathway?

Since 2008, we’ve been “starting with Spontaneous Awakening Trials (SATs) and Spontaneous Breathing Trials (SBTs).”

We know that implementing SATs and SBTs significantly reduces ventilation time and improves survival rates compared to continuous sedation. The evidence is clear: These practices lead to fewer patient complications.

But are we doing the best we possibly can for our patients?

With that question in mind, consider these impactful statistics:

Mobilizing patients within 48 hours post-intubation can increase their chances of going home by 24%, reduce delirium duration by two days, and enhance cognitive function by 20% per year after discharge.

A lack of mobility in the ICU results in higher rates of readmission and mortality within the first year after discharge.

For every additional 10 minutes of mobility, there’s a corresponding 1.2-day reduction in length of hospital stay.

ICU mobility can decrease hospital readmission rates by a staggering 59%.

The inability to stand three months post-ICU discharge increases the risk of mortality by 4.2 times in the first year.

Mobility during mechanical ventilation, even with an endotracheal tube in place, is remarkably safe, with an adverse event rate of just 0.6%.

Given these proven benefits for both patient outcomes and cost savings, how prevalent is early mobility in the ICU?

And does starting “slow” with just awakening and breathing trials really pave the way for successful early mobility?

A German study, published in 2014, revealed that only 24% of ICU patients were mobilized out of bed, with a mere 8% of intubated patients receiving the same treatment.

The first ABCDEF Bundle rollout, published in 2019, showed high compliance for SATs and SBTs among more than 15,000 patients across 68 facilities, yet only 12% of patients got up on their feet.

Most recently, a 2025 report covering 135 ICUs across 54 countries found that less than 10% of intubated patients were mobilized.

And after training 13 ICU teams and connecting with many more worldwide, I believe that “starting slow” might actually be creating a “failure to launch.”

As my friend, Margaret Arnold, aptly put it, trying to ease into an early mobility program is akin to water-skiing with your skis stuck halfway in the water.

Because if you never fully commit and get on top of the water, you’ll quickly exhaust yourself from battling the resistance.

For those who haven’t been at the bedside conducting awakening trials, let me clarify this further.

Starting continuous sedation is like pulling the pin from a grenade, and in many ICUs, this practice gets perpetuated from shift to shift without being re-evaluated.

And as you can see in the image below, SATs and SBTs are found on the same page in publications and taught as interdependent, and as a result, sedation often isn’t revisited until ventilator settings are at a minimum and all signs of critical illness appear to have resolved.

Consequently, patients may remain restrained and sedated in bed for days, leading to a staggering 3,095% increased risk of delirium if sedation continues beyond seven days.

In any case, each day of delirium corresponds to a 10% increased risk of death.

And while there might be a daily on-and-off toggle for sedation, it rarely aims to maintain patients in a fully awake state that promotes autonomy, mobility, or even communication.

The Hard Truth of ABCDEF Bundle Implementation

Continuous sedation increases the risk of delirium by an alarming 226%.

So, when sedation is finally turned off for a SAT, patients often emerge anxious, restless, and even panicked.

The terrifying experiences they’ve endured while sedated come rushing back, and as a result, restraints may be applied, and sedation resumes – leading to devastating outcomes.

This sequence of events is one of the main reasons why ABCDEF Bundle implementation fails.

This is echoed in findings from the recent TEAM trial, and as I discussed in Episode 117 of my Walking Home From The ICU podcast, this trial identified sedation and agitation as the primary barriers to mobility after six days of sedation.

We must recognize that by clinging to the outdated practice of automatically sedating patients post-intubation, we inadvertently create obstacles to their mobility.

This exacerbates delirium and ICU-acquired weakness, complicating mobility efforts significantly.

All things considered, we must stop treating the ABCDEF Bundle as nothing more than a sequential checklist.

Instead, we must view it for what it is – a collection of evidence-based practices that are most effective at enhancing patient outcomes when performed together.

The truth is, practicing the Bundle letter by letter is simply not feasible, as each component is interconnected and reliant on at least two other elements. For example:

“A” for Assessing, Preventing, and Treating Pain

Sedation often restrains patients chemically, making it difficult for them to articulate or express their pain.

That being said, the “A” in ABCDEF Bundle flourishes when patients are awake, cognitively engaged, and empowered to communicate the severity, type, and location of their discomfort.

“C” for Choice of Sedation and Analgesia

Keeping patients awake while intubated is challenging if they’re not mobilized to address anxiety, pain, tube tolerance, and prevent or manage delirium.

As such, the “C” in ABCDEF Bundle prompts us to critically evaluate whether sedation is even necessary.

“D” for Assessing, Preventing, and Treating Delirium

Properly addressing delirium is impossible when patients are routinely given sedatives that can induce delirium, leaving them unable to mobilize or engage with family members.

Once delirium sets in, awakening trials become arduous as patients may exhibit confusion, impulsivity, and are 11.6 times more likely to self-extubate.

Their heightened anxiety can also lead to tachypnea, causing failed breathing trials.

“F” for Family Engagement

It’s tough for families to connect with and support patients who are chemically restrained, unresponsive, and unable to convey their needs.

But by avoiding sedation, we can mobilize patients promptly, thus preventing and treating delirium.

This, in turn, often reduces anxiety and agitation, protecting patients from the cycle of starting and resuming sedation.

And regardless of what perspective we choose to take on this issue, the fact of the matter is, if we cling to automatic sedation and continue with traditional approaches to SATs and SBTs, we will inevitably struggle with ABCDEF Bundle implementation.

If we delay the cessation of sedation until we evaluate for extubation, or treat SATs like vacations, breaks, interruptions, or holidays, we will find ourselves contending with issues like delirium and ICU-acquired weakness.

As a result of this lack of proper ABCDEF Bundle implementation, clinicians will say things like:

“Patients will self-extubate if we don’t sedate them.”

“Our patients are ‘too sick’ to be mobilized.”

“We don’t have enough staff for early mobility.”

To be fair, in the current ICU landscape, we may not have sufficient staff to mobilize every patient in a unit filled with delirious and weakened individuals.

Furthermore, we must acknowledge that keeping patients on ventilators and hospitalized for extended periods of time – only to later readmit them – places a burden on our resources, which are already stretched thin.

From my personal experience, and through the teams I’ve trained, I’ve observed that when health care teams prioritize keeping every patient awake and communicative shortly after intubation, they encounter far fewer challenges with agitation, as they do during traditional awakening trials.

Mobilizing patients within 12 to 24 hours of intubation enables them to move independently, follow commands, and engage meaningfully with their care teams.

What’s more, the incidence of delirium and ICU-acquired weakness significantly decreases, and staff often say things like, “Wow, this is so much easier. I really love this!”

With that in mind, I encourage you to listen to several episodes of my Walking Home From The ICU podcast, including:

Episode 178: The Power of Nursing Leadership to Revolutionize the ICU, which features assistant nurse manager, Andrea Silva, BSN, RN, who shares her journey toward revolutionizing care in her ICU.

Episode 185: The ICU Revolution at Mercy San Juan Medical Center Part 4, featuring nurses from the Mercy San Juan trauma ICU, who explain how keeping patients awake and mobile has impacted their career fulfillment and team dynamics.

Episode 38: “THEY’RE AWAKE?!?” and Episode 114: From the Eyes of a Travel Nurse, which both feature travel nurses who compare their workloads in Awake and Walking ICUs to that of “normal ICUs” during COVID-19.

The insights offered in these episodes confirm that preventing delirium and ICU-acquired weakness is far simpler than treating these issues after the fact, and what we do at the onset of critical illness profoundly influences subsequent outcomes and workload.

Ultimately, until we master the art of keeping patients awake and mobile early on, we will miss out on the joy, success, and ease that the ABCDEF Bundle can truly offer.

Do you need help with ABCDEF Bundle implementation? If you’re ready to create an Awake and Walking ICU, please don’t hesitate to book a free consultation.

[daytonicuconsulting]

What Clinicians Need to Know About Awakening Trials

I have to admit, I wasn’t a fan of awakening trials at first.

During my first two years in an Awake and Walking ICU, we rarely initiated sedation, so the need to turn it off wasn’t a struggle for us.

When sedation was necessary, we simply turned it off when we deemed it unnecessary.

It wasn’t until my third travel assignment – three years into my critical care journey – that I encountered awakening trials.

“Here, we do this annoying thing at 5 a.m.,” they said. “You turn off sedation, and when you see them move, you turn it back on. That indicates they haven’t had a stroke and can tolerate the ventilator. Just chart ‘failed awakening trial’ in this SAT category.”

At the time, it made no sense to me.

What was the objective? This wasn’t a full neuro exam.

Why did patients react this way? And what did they need?

Despite my confusion, I had been worn down by demeaning responses to my previous questions about sedation, so I held my tongue and followed orders.

However, the stress of conducting these “awakening trials” at the end of my night shift was overwhelming.

Often, I was alone, unaware of how or when the patient would emerge from sedation.

Patients might remain quiet and then suddenly become wild just as I was attending to others.

When this happened, patients often tried to pull out their tubes, and in these instances, I had been directed to turn the sedation back on.

At the time, this baffled me, as I had already seen hundreds of intubated patients who were fully awake, calm, compliant, and even unrestrained.

So, why were these patients so “tube intolerant?” What made them different?

And why was this experience so much more challenging than in my first ICU?

What I Wish I’d Known About Awakening Trials

Like all ICU clinicians, I became a nurse because I’m passionate about saving and preserving people’s lives.

However, after starting my work as a nurse in an Awake and Walking ICU, and then working in several conventional ICUs, I became quite disheartened, as I could see that ICU culture has created many barriers to providing the absolute best evidence-based care.

With that in mind, here’s what I wish I’d known about awakening trials back then:

Delirium Increases the Risk of Self-Extubation

Delirium can increase the risk of self-extubation by 11.6 times, continuous sedation raises the risk of delirium by 216%, and more sedation correlates with increased severity of delirium.

Most patients I encountered in my first ICU remained awake, calm, and unrestrained because they were free of sedation after intubation.

They were quickly allowed to wake up so they could become oriented to their condition and tubes, which helped keep their movements safe. They could also connect with family, communicate their needs, and get quality sleep – all factors that mitigate delirium.

Patients who are not delirious can better cope with the endotracheal tube, as they can understand its necessity for survival, and they can actually articulate their needs and help respiratory therapists optimize their comfort settings.

Awakening Trials Aren’t Just an On/Off Switch for Sedation

In the early ‘90s, spontaneous breathing trials showed that patients who had sedation and the ventilator turned off to test their ability to be off of ventilator support did significantly better, and this led to the development of spontaneous awakening trials.

Over time, words like trials, interruption, break, holiday, and vacation became common in ICU sedation discussions.

Unfortunately, these terms suggest a temporary break from sedation rather than a re-evaluation of its necessity, which encourages clinicians to continue using these kinds of outdated practices.

The Purpose of Awakening Trials Is to Assess Sedation Needs

In the Awake and Walking ICU, we initiated this assessment promptly after intubation – unless specific conditions indicated that sedation was necessary.

We allowed patients to promptly awaken and communicate their needs via pen and paper, or even by texting on cell phones.

If a patient was at a RASS of +3 or +4, we employed light sedation like dexmedetomidine to calm them down to a RASS of 0 or +1, where we could safely facilitate mobilization and communication.

Our goal was to attempt to discontinue the daily use of sedation.

For patients unable to oxygenate with movement due to severe ARDS, for instance, we would stop sedation each day to gauge their oxygen saturation during movement, and if they maintained appropriate levels, sedation would remain off, allowing us to focus on mobility.

In any case, awakening trials are not just used to determine if a patient is ready to extubate.

Their main purpose is to ensure patients are only sedated when necessary, pushing for sedation cessation rather than just a brief interruption.

The ABCDEF Bundle’s Objective Is Critical

The aim of the ABCDEF Bundle is to keep patients as awake, communicative, autonomous, and mobile as possible, even early on after ICU admission and intubation.

And if we as clinicians want to provide the best possible care for our patients, then working toward that objective is absolutely critical.

As Dr. Wes Ely says, “Awakening trials are for the rehumanization of the patient,” which means we allow them to move, communicate, and be involved in their journey through the ICU.

When to Do Awakening Trials

The image above shows a common SAT and SBT algorithm.

These prompts show valuable guidelines to help clinicians critically think, but I have witnessed in my own practice and within dozens of other teams that these prompts are misinterpreted.

For example, agitation is listed as criteria for a failed awakening trial. Yet we are seeing at the bedside that a RASS of +1, which indicates that a patient is restless, is being charted as agitated, the awakening trial is deemed a failure, and sedation is being resumed.

Instead, this kind of protocol should use objective RASS scores, with a RASS of >+2 indicating a failed SAT.

At any rate, I suspect that having SAT and SBT criteria on this same page has led to the myth that SATs are for SBTs.

However, SATs should be done as soon as we suspect there is no longer an indication for sedation.

For many patients, this can and should be done once the paralytics for intubation are no longer in effect. We do NOT need to wait until we are doing a breathing trial to do an awakening trial.

And despite what I was told in that one ICU, movement does not indicate a failed awakening trial.

How to Respond to an Actual Failed Awakening Trial

If an awakening trial is actually deemed a failure, sedation should be resumed, but at half the previous dose.

However, despite this being a part of most hospital policies, this strategy is often overlooked in clinical practice.

At any rate, after an awakening trial, resuming sedation at the same dose or higher undermines the goals of maintaining patient wakefulness, autonomy, and mobility.

One randomized controlled trial showed that the awakening trial group ultimately received more sedation than the control group, which never received any “breaks” from sedation.

All things considered, just because awakening trials are required in the charting or even mentioned in rounds does not mean that they are being done properly.

A Strategic Approach to Stopping Sedation

Awakening trials are often late, inconsistent, poorly executed, or yield low success rates due to insufficient education and strategy.

My initial dread of these trials stemmed from the stress of managing a delirious, agitated patient alone during night shifts, which basically set things up to fail.

In any case, all clinicians in the ICU must have a shared understanding of the risks associated with sedation and immobility.

Together, we should aspire to keep patients awake, communicative, autonomous, and mobile shortly after intubation.

And when sedation is indicated, it’s essential for our teams to collaborate and adopt a strategic approach to help patients wake up as soon as possible and acclimate to the endotracheal tube.

Just as importantly, whenever a patient first opens their eyes, their loved ones should be present at the bedside.

These family members play a crucial role in maintaining a calm environment, helping the patient understand the tube, assisting with communication through writing or texting, or simply being there as a reassuring presence.

What’s more, ICU teams need to be competent in managing ventilator settings, securing the tube, and conducting pain assessments, all of which aid patients in adjusting to intubation.

And if a patient shows signs of delirium, the nurse should be prepared to call in a “delirium SWAT team,” which includes physical therapists, occupational therapists, and speech therapists.

Moreover, rather than resuming sedation at full dosage, nurses should strive to keep patients awake enough to engage in physical therapy and occupational therapy, working toward sitting on the edge of the bed and, hopefully, standing or walking.

This approach often results in patients becoming calmer and more adjusted to their surroundings, and it makes it easier for RNs to manage patients after mobility efforts.

Final Words

The “vacation” time for sedation needs to end.

We must shift our semantics, culture, and perspective from automatic sedation for all and a quick on/off approach to actively working toward avoiding and minimizing sedation usage unless it’s absolutely necessary.

What’s more, as I’ve pointed out countless times, like on Episode 4 of my Walking Home From The ICU podcast, it’s crucial for clinicians to recognize that sedation is NOT sleep.

Among other things, prolonged sedation increases the risks of delirium, ICU-acquired weakness, mortality, long-term brain injury, and PTSD.

It’s also important to point out that resuming sedation in response to signs of discomfort does not adequately address agitation or anxiety, and it often plunges patients deeper into traumatic delirium.

All things considered, it’s time to move beyond the SAT and SBT culture of the 1990s and start embracing the critical thinking and interdisciplinary collaboration that are required to foster the development of Awake and Walking ICUs.

Do you want your team to master the ABCDEF Bundle? If you’re ready to create an Awake and Walking ICU, please don’t hesitate to book a free consultation.

[daytonicuconsulting]

Reviving Core Nursing Values in Critical Care Through the ABCDEF Bundle

Critical care is an extraordinary and complex specialty that’s continually evolving, with a growing capacity to save and extend life in the face of the most extreme perils.

Research, knowledge, and technological developments have transformed nursing skills and our ability to care for patients who are critically ill.

Unfortunately, the nursing values and ethics, which should be informing the care we provide, have struggled to remain a guiding force in critical care nursing.

Part of the reason for this is that nurses continue to be saddled with a growing list of responsibilities – expected to monitor dozens of numbers, and numerous lines, drains, and devices, while juggling multiple providers and procedures, and being burdened with insurmountable charting.

And this ever-increasing list of duties exacerbates the assembly line approach to ICU care that automatically sedates and immobilizes patients when there’s no indication for it.

Fortunately, things don’t have to be this way, as more and more clinicians are learning that the evidence-based protocols found in the ABCDEF Bundle offer a better way to care for ICU patients.

The ABCDEF Bundle provides tools that guide ICU teams to keep patients as awake, communicative, autonomous, and mobile as possible during critical illness.

The Bundle challenges decades of culture in critical care medicine that is rooted in automatic sedation and immobility for all intubated patients on mechanical ventilation.

This begs the question, as the roles and duties of nurses grow with critical care medicine, can we preserve our original mission, and maintain our nursing values?

Have we left behind the core nursing values of autonomy, accountability, compassion, curiosity, professionalism, altruism, and innovation?

Or can the ABCDEF Bundle help to realign nurses with the core values and ethics of nursing?

How Nursing Values Are Lost in Current ICU Culture

Working in a system-based environment with an ingrained culture of sedation and immobility makes it all too easy to lose sight of the human being inside every sick body.

And the most effective way to dehumanize patients in this way is to ignore nursing values by depriving them of their autonomy, ability to communicate, connection with loved ones, and their physical function and independence.

In other words, the best way to dehumanize a patient is to sedate them.

With that in mind, let’s explore how the standardization of automatic sedation and immobility for all patients on mechanical ventilation creates significant barriers to the preservation of nursing values in the ICU.

Autonomy

When patients are sedated, they are no longer allowed to be part of their journey and are deprived of autonomy.

They are not able to be informed, communicate their wants and needs, and are shut out of being involved in making decisions for their own bodies and lives.

Even after sedation is discontinued, delirium and ICU-acquired weakness from sedation leave many patients vulnerable, dependent, and still deprived of autonomy.

Compassion

Nurses are innately deeply compassionate, but it’s challenging to know patients as unique individuals when they’re unresponsive.

It’s also easy to lose compassion, as patients can become more like a bag of physiology with the only sign of life being the monitors showing vital signs.

When they’re sedated and unable to connect with their caregivers, it’s impossible for nurses to know what patients are experiencing and just as difficult to meet their emotional, spiritual, and physical needs.

Altruism

Nurses have altruistic intentions, but the cultural norm of routine continuous sedation for all patients fails to protect patients from harm.

For example, delirium doubles the risk of dying in the hospital, and increases the risk of long-term brain injuryby up to 120 times, and continuous sedation increases the risk of delirium by 216%.

Nurses unknowingly orchestrate life-threatening and life-altering harm in the form of delirium and ICU-acquired weakness, as a result of sedation and immobility. This is far from true altruism.

Curiosity

Sedation and immobility culture has been inherited from generations of clinicians over the past three decades and it continues to go unquestioned.

In most ICUs, if a patient is going to be intubated, they will be sedated and comatose regardless of the nuances of their condition. This trained blindness deprives nurses of the value of curiosity.

And as a result of this lack of curiosity, they are not taught to ask questions like:

“Is my patient in pain?”

“What do they want and need for their care?”

“Is sedating them necessary and following best practices?”

“How can we protect their brain and muscles during critical illness?”

“How can I preserve their autonomy during mechanical ventilation?”

“How can they connect with their loved ones for support during their critical illness?”

Instead, they’re pressured to accept the malignant normalcy of automatic sedation and immobility and continue “what has always been done.”

Innovation

The conveyor belt routine of immediate continuous sedation after intubation and throughout mechanical ventilation removes the demand to understand and meet the patient’s needs.

These cultural norms instill a “one-size-fits-all” mentality that stifles nursing innovation.

Accountability

An ICU environment that follows cultural sedation practices rather than evidence-based sedation management does not hold nurses accountable.

And when nurses aren’t adequately trained, supported, and monitored, then RASS scores, for instance, can become inaccurate, delirium screening won’t be performed correctly, and awakening trials aren’t successfully executed.

Patients remain comatose and in bed without further assessment or regulation.

Professionalism

Such a culture persists in oblivion to the harm sedation and immobility cause.

Unfortunately, this can also create tension between disciplines when a physical or occupational therapy colleague attempts to challenge sedation administration and advocate for early mobility.

Nurses who are not educated in the latest evidence-based practices, like those found in the ABCDEF Bundle, may become fearful of having patients awake and mobile, as they’re unsure of how to navigate these new situations with professionalism.

The Shift to Awake and Walking ICUs

An Awake and Walking ICU will have a team that prioritizes keeping patients as awake, communicative, autonomous, and mobile as possible.

And they achieve these objectives through the use of the ABCDEF Bundle, which is a collection of tools to help manage patients during critical illness and help them to survive and thrive.

Some of the key components of this approach include:

Giving sedation only when there is an indication for it

Using the safest sedative at the lowest dose for the shortest duration possible

Ensuring patients are promptly performing their highest level of mobility, unless there is a contraindication

Eliminating visitation restrictions for loved ones

This approach empowers nurses and reconnects them with the core nursing values that should be informing their care.

With that in mind, let’s look at how these nursing values are applied in an Awake and Walking ICU.

Autonomy

Ensuring patients are promptly awakened after intubation keeps their cognition and fine motor skills intact so they can be autonomous and communicate using non-verbal methods.

They’re informed of their condition and involved in decision-making about their treatments, and they remain as strong and mobile as possible to do as much as they can for themselves.

Compassion

Preserving patients’ ability to communicate helps nurses get to know patients personally, aside from just their sick bodies.

This inspires compassion as nurses come to understand and care about what matters to each individual patient, and it allows them to better identify and address patients’ personal needs.

Moreover, they’re able to know and honor their patients’ wants and wishes and can also educate patients’ families on what’s happening with their health and keep them engaged with their loved ones.

Altruism

The ABCDEF Bundle decreases 7-day mortality by 68% and protects patients from the suffering and potentially life-long disability of post-ICU syndrome, which occurs as a result of delirium and ICU-acquired weakness.

This enables nurses to be better equipped to heal their patients from critical illness without causing more harm, which gives patients the best chance to survive and thrive in and after the ICU.

What’s more, this approach empowers nurses to master altruism in their practice.

Curiosity

In order to transform sedation and mobility practices in the ICU, nurses have to be curious and open to learning more.

They must utilize the most up-to-date evidence to overcome long-established beliefs and culture they’ve inherited from past generations of clinicians.

In addition, they have to be willing to try new things, develop new skills, and foster a curiosity for who each patient truly is, what they’re experiencing, and what they need and want for their care and for their lives.

Remaining curious will help them find ways to ensure each patient can stay as awake and mobile as possible during critical illness.

Accountability

An Awake and Walking ICU encourages each clinician to ask questions like, “Is there an indication for sedation?” and “Are we protecting this patient from delirium and ICU-acquired weakness?”

This type of ICU team demands accurate documentation and routine reviews of data to ensure that patients are receiving the highest dose of the ABCDEF Bundle as possible.

This kind of culture brings in a high level of accountability for nurses as they learn to use sedation cautiously while accurately assessing for delirium and promptly mobilizing patients.

Professionalism

The responsibility for the implementation of the ABCDEF Bundle does not solely fall on the shoulders of nurses.

It does, however, provide an opportunity for nurses to exemplify professionalism as they work collaboratively with their colleagues from other disciplines.

This helps them to develop their professionalism, as they come to understand and respect the expertise that each member of the ICU team offers.

Innovation

Although the ABCDEF Bundle is not a new concept, it does require an innovative spirit, especially for teams that continue to prioritize automatic sedation and immobility for all intubated patients.

Nurses must be open to a new approach to care and demonstrate innovation as they strive to keep their patients awake, communicative, autonomous, and mobile.

Final Words

Without a doubt, Awake and Walking ICUs are the future of critical care medicine.

And through education, training, safe staffing, interdisciplinary collaboration, and an evidence-based culture and practices, the ABCDEF Bundle will help clinicians to revive the core nursing values that will allow us to transform patient care and outcomes.

Do you want your team to master the ABCDEF Bundle? If you’re ready to create an Awake and Walking ICU, contact me today or use my calendar to book a free consultation.

[daytonicuconsulting]

How Failing to Practice the ABCDEF Bundle Creates Legal Liabilities in the ICU

As a nurse and a nurse advocate, I am passionate about protecting nurses and all ICU clinicians from falling victim to legal liabilities in the ICU.

The alarming reality is that when hospitals fail to train and support their teams in keeping patients as awake and mobile as possible, everyone from hospital administrators to bedside clinicians are vulnerable to legal liabilities.

If hospitals are not practicing the ABCDEF Bundle, they are not complying with standard of care and are allowing significant risk and harm to happen to patients.

The ABCDEF Bundle has been proven to give patients the best opportunity to survive and thrive.

Even with subpar compliance, it has been proven to decrease:

7-day mortality by 68%

Coma and delirium by 25-50%

Readmissions to the hospital by 46%

Discharges to anywhere but home by 36%

It’s also important to note that these outcomes are dose-dependent, so the less sedation is given, and the more patients are mobilized, the better all of these outcomes will be!

We also know that early mobility specifically decreases:

Hospital-acquired pressure injuries

Long-term cognitive impairments

Long-term physical disability

Hospital-acquired infections

Delirium

Falls

In addition, we know that avoiding sedation decreases:

PTSD

Death

Time in the ICU

Physical disability

Chronic brain injuries

Time on the ventilator

Discharges to care facilities

The ABCDEF Bundle was first implemented in many ICUs throughout the U.S. between 2016 and 2019.

Unfortunately, in many units, the only evidence of the ABCDEF Bundle today is in charting prompts in the electronic health record (EHR).

So, what are the legal liabilities in the ICU when a team fails to provide the evidence-based care outlined in the ABCDEF Bundle?

Let’s take a deeper look at this issue and find out.

How Can Failing to Practice the ABCDEF Bundle Cause Legal Liabilities in the ICU?

In Episode 179 of Walking Home From The ICU, I interviewed Maggie Ortiz, RN, MSN, who is an expert nurse advocate.

During our conversation, I was shocked to learn that when it comes to the ABCDEF Bundle, hospitals, their leadership, and the clinicians who staff them, are vulnerable to several issues related to what would be considered false documentation.

Believe it or not, this is a very common occurrence, as certain elements of the ABCDEF Bundle are required in the EHR, but often, the charting is not accurate, and this is where problems can arise related to false documentation.

To put things in perspective, below I’ve detailed several examples of how this sort of thing tends to happen in the ICU.

Richmond Assessment Sedation Scale (RASS)

The Richmond Assessment Sedation Scale, or RASS, is a tool to measure patients’ psychomotor activity and is most often used to titrate sedation.

For example, when a provider orders a continuous sedative drip, it is usually ordered for a RASS score rather than a certain dose of sedation.

Thanks to past ABCDEF Bundle initiatives by the Society of Critical Care Medicine, most sedation order sets have a preset RASS score range of 0 to -2.

This means that patients are somewhere between completely awake to sedated to the point of being able to open their eyes to voice and make eye contact for less than 10 seconds.

RASS should be charted every 2-4 hours and PRN for patients on continuous sedation or analgesia.

As I have teams perform manual audits, they compare the prescribed RASS to the documented RASS to the actual RASS the auditors observe at the bedside.

Among the numerous teams that have provided me with their audit results, 50-80% of their documented RASS scores are inaccurate.

And as I discussed in Episode 134 of Walking Home From The ICU, about 60% of those inaccurate scores are at least two points too high.

This means that nurses are charting a RASS that reflects light sedation when patients are actually deeply sedated. This is false documentation, similar to charting fake vital signs.

Confusion Assessment Method (CAM-ICU)

The Confusion Assessment Method, CAM-ICU, or CAM, is a powerful tool used to diagnose ICU delirium.

It’s the equivalent of using creatinine to assess for renal function.

Depending on the facility and state, CAM screening is required to be done and documented 1-3 times every 24 hours.

Some teams may seem to have high rates of compliance with CAM charting, but upon further investigation, it is very common to see “UTA” charted, which means unable to assess.

If a nurse documents a RASS of -2 and “UTA” for CAM, this may be a sign of false documentation.

The only valid possibility is that the patient does not speak English.

Otherwise, the patient is sedated deeper than a RASS of -2 and the RASS score is falsified, or the nurse did not perform the CAM at all. This is false documentation.

It is also very common for nurses not to perform the CAM, but rather, base their documentation off of a patient’s ability to follow commands.

This is also false documentation and can be considered equal to falsifying a lab value.

Mobility Screening

Mobility screening is required in the EHR to document a patient’s level of mobility, and it’s usually required every 12 hours.

It may seem compliant if there is any charting present, however, a closer look often reveals “bedrest” documented for most patients in the ICU.

But when a patient’s true mobility level is not bedrest, and there is no contraindication to mobility, this can also be considered false documentation.

Spontaneous Awakening Trials (SAT)

The term spontaneous awakening trial, or SAT, refers to the process of turning sedation and analgesia off to assess for continued necessity of sedation and analgesia.

This should be done at least every 24 hours unless there is a contraindication, and it should be charted as either a pass or a fail.

However, if a SAT is charted as failed, but there is no sign of sedation being turned off, this may be a sign of false documentation.

And if it’s documented that a SAT was failed and the reason was agitation, yet the highest RASS is +1 (restlessness), this may also be considered false documentation.

Spontaneous Breathing Trials (SBT)

The term spontaneous breathing trial, or SBT, refers to when adjustments are made to the ventilator that allow the patient to take their own spontaneous breaths with minimal to no support from the ventilator.

This is used to assess the patient’s readiness to be taken off of mechanical ventilation.

If an SBT is failed, then the respiratory therapist is obligated to document which criteria were unmet.

However, it has been observed that this documentation can be falsified with answers that are untrue and do not apply to the patient, and this is also considered false documentation.

More Examples of Common ICU Legal Liabilities

Aside from the aforementioned issues associated with false documentation, there are many other issues related to the ABCDEF Bundle that can create legal liabilities in the ICU.

Whether it’s problems with prescriptions, failing to properly assess each patient, failing to properly treat them, or something else altogether, these missteps can cause some serious legal issues.

With that in mind, let’s look at several other potential legal risks in ICU care.

Administering More Medication Than Is Prescribed

When nurses sedate patients to a RASS that’s lower than what’s been prescribed, they are giving more medication than what’s been prescribed.

The medications in question include controlled substances like opioids and benzodiazepines, and when nurses do this, it’s basically like practicing medicine without a license.

One study showed that despite an ordered RASS of -3, 70% of patients were deeply sedated to a RASS of -4 and -5.

This is alarming considering that deep sedation is an independent predictor of death.

We see this trend in the research, where although the charted RASS scores were similar between day and night shift, the doses of sedatives and opioids were increased at night, which is likely false documentation.

When a SAT is failed, most hospital policies require nurses to resume the sedation at half of the previous dose.

Unfortunately, it’s a common cultural practice to resume the sedation at the previous dose, and sometimes even increase the dose.

This is giving more medication than has been prescribed, it’s going outside the RN scope of practice, and it’s against hospital policies.

Failure to Assess

In addition to false documentation, and going outside the scope of your practice, failing to properly assess patients can also cause significant legal liabilities in the ICU.

Having said that, let’s look at some situations where ICU legal liabilities can be caused by failing to properly assess patients.

RASS

When RASS documentation is not performed, this is a failure to assess.

In these situations, high risk and controlled substances are being given without monitoring and/or accurate doses.

And obviously, if this sort of thing ever went to court, it could be extremely damaging to both the hospital itself and all the clinicians who were involved.

CAM-ICU

In some ICU teams, CAM-ICU has 0% documentation, which means that patients are not being screened or assessed for acute brain failure.

But when you consider that delirium doubles the risk of dying in the hospital, this failure to assess is dangerous to patients and a significant liability for both hospitals and clinicians.

Failure to Treat

Aside from everything I’ve already mentioned, failing to properly treat patients can also create major legal liabilities in the ICU.

That being said, let’s look at several ICU legal liabilities that can be caused by failing to properly assess patients.

Delirium

Unfortunately, most ICU teams are not trained to adequately treat delirium.

This results in a failure to treat this condition using the proper interventions like avoiding medications that cause delirium, and facilitating real sleep, family engagement, and mobility.

Because when patients demonstrate symptoms of delirium, such as restlessness, anxiety, confusion, and impulsiveness, they are often given more deliriogenic sedatives.

But giving sedation in response to delirium could be likened to giving bacteria for sepsis.

Yet, in the ICU, this is common practice, and it’s considered culturally acceptable to respond to delirium with even more sedation.

ICU-Acquired Weakness

Patients quickly lose muscle mass and function in the ICU while sedated and immobilized, and this can lead to the life-threatening condition known as ICU-acquired weakness.

Most ICU teams are not trained to prevent and treat this condition, so when signs of this are observed, like limb weakness and failed SBTs, the response is to resume sedation and/or keep patients in bed.

The proper treatment for ICU-acquired weakness is to initiate mobility, but the cultural response is to chart “bedrest” as their level of mobility and to avoid mobility altogether.

No matter how you look at it, this can be considered a failure to treat.

Mobility

Physical and occupational therapists face significant challenges when it comes to properly providing their services in the ICU.

If they’re fortunate enough to be consulted, they still face barriers related to sedation and a lack of interdisciplinary collaboration.

For example, culturally, nurses have the final say in many ICUs, and it’s common for nurses to tell physical and occupational therapists, “This patient cannot be mobilized.”

Yet, physical and occupational therapists have their master’s and doctorate degrees, and they specialize in early mobility.

That being said, if they were to be questioned about not mobilizing a patient they were consulted on, would “The nurse wouldn’t let me,” hold up in court?

Or would they also be held liable for failing to prevent, assess, and treat delirium and ICU-acquired weakness?

Elder Abuse

As our patient population in critical care continues to age, we must provide age-friendly treatment.

But automatically sedating and immobilizing geriatric patients does not comply with the 4Ms frameworkbeing rolled out throughout our health care system.

With that in mind, ICUs that are administering benzodiazepines, prioritizing deep sedation, failing to prevent, screen for, and treat delirium, and immobilizing vulnerable geriatric patients may not fare well in the courts.

Final Words

ICU culture is a powerful and blinding force that can stop clinicians from questioning what is right and what is best for patients.

As a result, the potentially illegal practices I detailed above tend to be performed in ignorance.

As I explained in Episode 1 of Walking Home From The ICU, even I can relate to this, as after working in an Awake and Walking ICU, I too fell into the same harmful practices as my colleagues when I worked in other ICUs.

In any case, clinicians deserve to be educated and empowered to provide the best possible care for patients using the most up-to-date evidence-based practices.

But when an ICU culture does not allow for and encourage these best practices, everyone is at risk of being held legally liable.

It is terrifying to realize that major auditing organizations and local leadership are unaware of the importance and impact of the ABCDEF Bundle, not least in how it offers protection against potentially devastating legal liabilities.

But as I discussed in Episode 95 of Walking Home From The ICU, what if reimbursement agencies realized that failing to practice the ABCDEF Bundle was increasing health care costs by 30%?

And what if survivors knew about all of this?

What if the many survivors whose stories I documented decided to hold the hospitals who treated them liable for the substandard care they were given?

What if Susanne sued the hospital where she was treated for the 13 extra days on the ventilator, delirium, ICU-acquired weakness, permanent PTSD and cognitive impairments she suffered while under their care?

And what if Jim sued the hospital that treated him for the tracheostomy, PTSD, cognitive impairments, physical disability, and preventable three months in the ICU/LTACH he had to endure?

In the near future, when the world realizes that what is considered normal in the ICU is not right, there may be a mass awakening to the true reality of these practices.

Will your team be at the forefront and already practicing the ABCDEF Bundle when this happens?

Do you want your team to master the ABCDEF Bundle? If you’re ready to create an Awake and Walking ICU, please don’t hesitate to sign up for a free consultation.

[daytonicuconsulting]

Diane’s Story: An Unfortunate Example of the Risks of Immobility and Sedation

Despite their widespread use in the ICU, decades of research have proven the risks of immobility and sedation.

And as clinicians, it’s easy to approach care as a robotic conveyor belt instead of focusing on the individuals, families, lives, careers, and futures that are being affected.

But in reality, ICU patients are being harmed, having their lives turned upside down, and even losing their lives as a result of prolonged sedation and immobility, which are both considered “normal practices” in the ICU.

The ABCDEF Bundle should guide us to minimize and even eliminate the risks of immobility and sedation.

However, if it’s not properly implemented, you’re unlikely to see any significant results, and you can even end up doing more harm than good.

With that in mind, this article explores how things like patient harm, workload, time on the ventilator, and time in the ICU can all be increased when the ABCDEF Bundle is treated as nothing more than a checklist.

This is a real scenario involving a real patient whose name has been changed for anonymity, and for the purposes of this article, will be referred to as Diane.

How Ignoring the Risks of Immobility and Sedation Damaged Diane

Diane is a 54-year-old female with a history of methamphetamine abuse.

She lives with friends in a trailer park, works as a cannabis washer, and has a son that lives an hour away from her.

Diane arrived at the emergency department on the evening of June 17, 2024, with shortness of breath and hypoxia.

She asked to be intubated, and following intubation, Diane had an FiO2 of 90% and a PEEP of 10 before being admitted to the ICU for acute respiratory failure secondary to multifocal pneumonia, septic shock, and acute kidney injury.

Her toxicology screen was positive for amphetamines and THC.

Day One

Diane was intubated in the emergency department and sent to the ICU.

Ventilator Settings: A/C FiO2 90%, PEEP 10

IV Infusions: Propofol 40 mcg/kg/min, Fentanyl 75 mcg/hr, Norepinephrine 14 mcg/min, Vasopressin 0.03 units/min

Day Two

Ventilator Settings: A/C FiO2 50%, PEEP 8

IV Infusions: Propofol 30 mcg/kg/min, Fentanyl 50 mcg/hr, Norepinephrine 2 mcg/min, Vasopressin 0.03 units/min

PRN Total: Midazolam 6 mg

Documented RASS: -2

SAT, SBT, CAM, Early Mobility: None

Day Three

Ventilator Settings: A/C FiO2 40%, PS 5, PEEP 8

IV Infusions: Propofol 30 mcg/kg/min, Fentanyl 25-50 mcg/hr

Documented RASS: -1 to +1

SAT: Propofol was off for 1.5 hours and then resumed in response to the RASS of +1.

SBT: Failed

CAM and Early Mobility: None

Day Four

Ventilator Settings: A/C FiO2 50%, PEEP 8

IV Infusions: Propofol 35 mcg/kg/min, Fentanyl 50 mcg/hr

Documented RASS: -2

SAT, SBT, CAM, Early Mobility: None

Day Five

Wound care was consulted for a dark area on the buttocks.

Ventilator Settings: A/C FiO2 30%, PEEP 5

IV Infusions: Propofol 35 mcg/kg/min, Fentanyl 50 mcg/hr

PRN Total: Midazolam 4 mg

Documented RASS: -2 to +1

SAT, SBT, CAM, Early Mobility: None

Day Six

Ventilator Settings: A/C FiO2 40%, PEEP 5

IV Infusions: Propofol 35 mcg/kg/min, Fentanyl 50 mcg/hr

PRN Total: Midazolam 4 mg

Documented RASS: -2 to +1

SAT: Propofol was turned down and then off for 10 minutes, but Fentanyl stayed on.

SBT: Failed

CAM: First charted at 19

Early Mobility: None

Day Seven

Ventilator Settings: A/C FiO2 90%, PEEP 10

IV Infusions: Propofol 50 mcg/kg/min, Fentanyl 150 mcg/hr

PRN Totals: Midazolam 16 mg, Oxycodone 20 mg

Documented RASS: -2 to +2

SAT: Propofol turned down and then turned back up.

SBT: Failed

CAM: +

Early Mobility: None

Day Eight

Ventilator Settings: FiO2 85%-60%, PEEP 10-8,

IV Infusions: Propofol 50 mcg/kg/hr, Fentanyl 150 mcg/hr

PRN Totals: Midazolam 10 mg, Oxycodone 40 mg

Documented RASS: -3 to +3/4

SAT, SBT, Early Mobility: None

CAM: +

Day Nine

Ventilator Settings: FiO2 50%, PEEP 8

IV Infusions: Propofol 50 mcg/kg/min, Fentanyl 150 mcg/hr

PRN Totals: Midazolam 32 mg, Oxycodone 40 mg

Documented RASS: -2 to +2

SAT: Propofol was briefly decreased for SBT, and Fentanyl was continued.

SBT: Failed

CAM: +

Day 10

Propofol was turned off and Diane was extubated and fitted with a high-flow nasal cannula.

IV Infusions: Fentanyl 60 mcg/hr, Precedex 0.5 mcg/kg/hr

PRN Totals: Haldol 15 mg, Midazolam 17 mg, Oxycodone 20 mg

Documented RASS: 0 to +1

CAM: +

Early Mobility: None

Days 11-14

On day 11, After being fitted with a high-flow nasal cannula, Diane started to assist with being turned in her bed.

Then, on day 12, she was transferred to a chair with PT and discharged to the floor, and on day 13, she finally took her first steps in her room.

On day 14, Diane left the hospital against medical advice with a deep tissue injury and cognitive impairments, and required a walker even for very limited mobility.

Discussion

The team that provided the details of this case study admitted that this was a “normal” scenario in their unit.

Unfortunately, it’s not just this ICU, and the following gaps are very common in the culture and practices of many ICUs throughout the world.

That being said, this discussion is not to single out or belittle one specific ICU team, but rather to reveal problems I have observed throughout the critical care community, including:

Automatic Sedation

Was automatic sedation appropriate for Diane? And did she even have an indication for sedation?

Or was this just the conveyor belt approach of the ED and ICU?

Nurses’ notes reflect that Diane was distressed and asked to be intubated.

It is unclear if she was actively under the influence of methamphetamine at the time, but the notes seem to reflect that she was in distress from acute respiratory failure and not actively high on methamphetamines.

Nonetheless, if the ICU team that treated her had stopped sedation when she arrived at the ICU to evaluate whether it was necessary, it would have completely changed the course of her treatment.

Turning off sedation promptly while Diane still had the capacity to understand her surroundings and situation and communicate her needs to staff likely would have led her to be extubated on day two or three rather than on day 10.

This would have also prevented her complications, including ventilator-associated pneumonia, delirium, a stage 3 pressure injury, and ICU-acquired weakness.

RASS Scores

Diane’s sedation was ordered for a RASS score of -2 to 0, and while sedated, her RASS was documented at -2.

But while I was reviewing her chart, I noticed that the respiratory rates in her vital signs documentation were consistently the same as the respiratory rate set on the ventilator.

This leads me to suspect that she was likely sedated closer to a RASS of -4 or -5, which inhibits her from taking spontaneous breaths.

Although this was not the intention of the nurses who treated Diane, charting a RASS of -2 when the RASS is actually -4 or -5 is false documentation, which results in giving more sedation than should be prescribed, and is outside an RN’s scope of practice.

A RASS of -4 or -5 is also an independent predictor of mortality and an independent risk factor for delirium.

Ultimately, Diane likely did not have an indication for sedation but was still deeply sedated without further thought.

Delirium Screening

Delirium is a form of acute brain failure that doubles the risk of dying in the hospital and increases the risks of long-term brain injury by 120 times.

Luckily, we have the CAM-ICU, which is basically the “creatinine for the brain” as it allows us to assess and diagnose delirium.

Although Diane had significant risk factors for delirium, including a history of drug abuse, sepsis, septic shock, and hypoxia, for whatever reason, she was still deeply sedated and immobilized, which are both known risk factors for delirium.

Nonetheless, she was not screened for brain dysfunction until the end of her sixth day in the ICU.

This is the equivalent of not checking a patient’s creatinine levels for six days in the ICU.

In any case, not treating the brain with this same level of diligence led to a failure to prevent, assess, and treat acute brain failure.

Spontaneous Awakening Trials

Spontaneous awakening trials should occur as soon as there is no longer an indication for sedation, and the goal should be to discontinue sedation unless there is a real indication for it.

But Diane didn’t receive her first awakening trial until her third day in the ICU.

After 1.5 hours, sedation likely metabolized out of her system and her RASS increased to +1, but still, sedation was promptly resumed.

ICU Liberation guidance states that failed SAT criteria include agitation, but the term agitation is very subjective.

A RASS of +1 is restlessness, but is that a level of agitation that requires sedation?

Restlessness is a symptom of root causes like pain, anxiety, fear, confusion, delirium, desperation to communicate, etc., all of which is only masked by sedation, not treated.

And if Diane emerged from sedation with restlessness at a RASS of +1, she should have been given a means to communicate her needs so they could be addressed.

She should have also been mobilized to treat her anxiety, improve her comfort and adjustment to the ventilator, and especially to get her extubated.

Instead, she was resedated to a RASS of “-2” which in reality was more like a RASS of -4 or -5.

This pattern of quickly turning sedation off and turning it back on in response to movement was continued for seven days, which resulted in seven extra days on the ventilator, profound and prolonged delirium, a large deep tissue pressure injury, and ICU-acquired weakness.

And although SATs are performed by nurses, the responsibility for these outcomes is not solely on the nurses.

Respiratory therapists (RTs), physical therapists (PTs), occupational therapists (OTs), and physicians also carry this responsibility, and should have been asking questions like:

“Why is she sedated?”

“Why is she at a RASS of -4?”

“And why aren’t we mobilizing her?”

The correct response in this situation should have been something like, “Her ventilator settings are minimal, so she should be strong enough to extubate. Let’s do the SAT and SBT together and get her extubated!”

Physicians especially needed to take the lead here, not least because they have the benefit of continuity of care and have the responsibility of critically thinking through the “big picture” and guiding their teams to see beyond that one shift or checklist.

For instance, when the physician was told in rounds that Diane failed the SAT and SBT, they should have probed further and asked:

“Why did she fail?”

“What criteria was unmet?”

“Why was she at a RASS of +1?”

“What did the RT see on the ventilator during the SBT?”

“Why was that happening and what can we do to fix it so we can get her extubated?”

Ideally, during rounds on day three and beyond, a physician should have said, “OK team, she is probably ready to be extubated. At this point, she is only intubated because she’s sedated and sedated because she’s intubated. But she’s at high risk of delirium and ICU-acquired weakness, so let’s get sedation off, get her mobilized, and get her extubated.”

The physician should have also been available to support the team and follow up to ensure those orders were followed through with and Diane was successfully extubated.

What likely happened here is common among many ICU teams:

The RN tells the RT, “They failed their SAT,” so the RT can’t do an SBT, or the RT reports to the RN that they failed their SBT, and the RN then resumes sedation.

Then, during rounds, the RN reports to the physician and team that the patient “failed the SAT and SBT” and the physician says, “OK, we’ll try again tomorrow.”

Typically, in these situations, a physical or occupational therapist may be present, but instead of speaking up, often they’ll just stay quiet and think to themselves, “OK, I guess we’ll see her when she’s extubated.”

But what they should be saying is, “Can I go in with you to do a SAT? I can help get her up and then we can try another SBT. What time works for you guys?”

However, this is not usually what happens.

Spontaneous Breathing Trials

By Diane’s third day in the ICU, her ventilator settings were fairly low, and she had met the criteria for trying a spontaneous breathing trial.

My suspicion is that if she had been awake, mobile, taking spontaneous breaths, and coughing, she would have been able to be mobile and clear her secretions from pneumonia more effectively, and therefore may have had an even lower PEEP by that time.

I was not present during this patient’s breathing trial, but speculations can be made as to why Diane “failed” her breathing trials, including:

Delirium: Diane was at high risk of delirium, and this can result in her becoming tachypneic and dyssynchronous with the ventilator.

Anxiety: Diane likely had poor coping mechanisms at baseline and emerging from sedation to realize you’re intubated and strapped to a bed with strangers looming over you would be anxiety-provoking for anyone. This can result in rapid and even shallow breathing.

Pain: Diane could have been in pain, as well, which could also have led her to have rapid or shallow breathing.

The image below shows the main causes of failed spontaneous breathing trials and the underlying causes of these failures, most of which are rooted in delirium and ICU-acquired weakness and can be treated using mobility.

All things considered, if this ICU team had the knowledge, perspective, and culture to critically think through Diane’s SBT, she would have been awake and mobile on day one.

The team would have been focused on a successful SBT shortly after intubation, rather than waiting until ventilator settings are minimal to finally think about how to get her off the ventilator.

And they would know that by keeping her awake and mobile they could prevent delirium and ICU-acquired weakness, expedite the improvement of her pneumonia, and keep her brain and muscles intact so she could independently breathe much sooner.

This way, by the time she was ready for an SBT, she wouldn’t need a SAT. She would already be awake, calm, and strong, and the SBT process would be simple and successful.

Instead, Diane’s SBTs were approached in a robotic way, with RTs simply checking the SBT box on their task list.

The RT changed the ventilator to spontaneous mode when the nurse stopped the Propofol, and likely looked at numbers like her respiratory rate and noted that they met failure criteria.

They then documented the SBT as failed, the RN resumed sedation, and the RT resumed a controlled mode on the ventilator.

Everything was documented, and it looked compliant on the ABCDEF Bundle dashboard, but was this actually the best approach for Diane?

In any case, empowering RTs to critically think through SBTs could have drastically changed this patient’s outcomes, and the workload and health care costs for the hospital where she was treated.

Mobility

In the ICU, the timing of mobility is imperative.

To prevent post-ICU syndrome, patients must be mobilized within 72 hours after ICU admission.

If patients are mobilized within 48 hours after intubation, this can improve their return to baseline functional status by 24% and improve cognitive function by 20% one year after discharge.

Mobility is also one of the only tools we have to prevent and treat delirium and keep the respiratory muscles intact so patients can independently breathe once the acute indication for mechanical ventilation is resolved.

The only exclusion criteria for mobility Diane met was that she was deeply sedated, although she should have been awake and mobile on day one.

The ICU team that treated her should have been anticipating that she’d be awake and walking on the ventilator to treat her pneumonia, prevent delirium and ICU-acquired weakness, and get her ready to be extubated and discharged home as soon as possible.

Instead, Diane didn’t get out of bed until day 12.

This could be charted as “bed rest” on the ABCDEF Bundle dashboard, which creates the appearance of compliance for screening.

But ultimately, the failure to promptly mobilize Diane was a failure to truly practice the ABCDEF Bundle.

The Price Paid

Health Care Costs

On average, one day in the ICU costs $5,521, and ventilator costs alone are $2,401 per day.

By my estimates, Diane probably could have been extubated on day two if she had been awake and walking and should have been extubated on day three at the latest.

At any rate, failing to truly practice the ABCDEF Bundle cost this ICU about $16,807 in ventilator costs alone.

Had Diane been extubated on day three, she likely would have been on a nasal cannula and sent to the floor. But instead, she stayed in the ICU until day 12, and those nine extra days in the ICU cost around $49,689.

On day seven, Diane developed ventilator-associated pneumonia (VAP), which on average costs $58,520.

She also ended up with a stage 3 hospital-acquired pressure injury (HAPI) which costs $8,371, but Diane would not have developed any of these complications if she had been made to be promptly awake and mobile.

Diane didn’t sue the hospital, but lawsuits for these kinds of pressure injuries cost hospitals about $200,000 on average.

And Diane may have saved this hospital some money by leaving early against medical advice.

Yet she left with severe cognitive impairments, weakness, and an untreated deep tissue pressure injury.

At this point, she is at high risk of readmission due to complications like infection in the pressure injury, pneumonia, falls, and more.

But if she’d been awake and mobile, Diane would have been much more likely to safely return to her home sooner and stay there.

Workload and Staffing

It’s likely that Diane was perceived as an “easy patient” since she was sedated and immobilized for most of her stay in the ICU.

But what many clinicians don’t realize is that failing to practice the ABCDEF Bundle in the way it was meant to be applied can drastically increase their workload.

For the seven extra days that Diane spent on the ventilator, here’s all the extra work ICU clinicians had to do:

Respiratory Department

Ventilator checks and charting every 4 hours: 42 extra times

Oral care every 4 hours: 42 extra times

Suctioning every 4 hours with ventilator checks: 42 extra times

More care sessions with ventilator checks, charting, suctioning, etc.

Spontaneous breathing trials: 5 extra times

Breathing treatments every 4-6 hours: 28-42 extra times

Setting up a high-flow nasal cannula after extubation

Registered Nurses

Oral care every 4 hours: 42 extra times

Turns every two hours: 84 extra times

Hourly documentation of vital signs: 168 extra times

Restraint assessment and documentation every 2 hours: 84 extra times

PRN suctioning about 10 times per 24 hours: 70 extra times

Daily bed bath: 7 extra times

PRN repositioning/boosting about six times per 24 hours: 42 extra times

Full assessment and documentation every 12 hours: 14 extra times

2-3.6 100 ml Propofol bottle changes per day: 18 extra times

1.2-3.6 changes of 100 ml Fentanyl bags per day: 14.8 extra times

RASS every two hours: 84 extra times

 Double-checking controlled substances

Restraint check and charting every two hours: 84 extra times

SAT: 4 extra times

Physicians

Recording daily medical notes: 7 extra times

70 extra minutes spent discussing in rounds

7 additional exams

Post-ICU Life

Diane has significant risk factors for post-ICU syndrome.

For every one day of delirium, for instance, there is a 35% increased risk of long-term cognitive impairments on the same level as mild Alzheimer’s and moderate traumatic brain injury.

It’s impossible to know exactly when Diane’s delirium started or ended, since she was not screened for delirium until day six, and not screened for it on the floor when she left against medical advice.

But she likely started to have delirium around day two after intubation.

The occupational therapy notes from her last day in the hospital indicate that she had persistent severe cognitive impairments, so at this point, she was either still damaged from delirium or still actively in delirium.

In any case, she likely suffered from delirium for at least six days, but it could have been up to 12 days or more.

Even at baseline, she probably had cognitive impairments due to her methamphetamine use, not to mention the fact that she was malnourished and lived with multiple friends in a trailer.

With this new trauma, cognitive impairments, mobility deficits, and large deep tissue pressure injury, will she be able to survive and thrive after leaving the hospital?

The rest of Diane’s story is unknown to me, yet I feel confident in assuming that post-ICU syndrome will play a significant role in the trajectory of her life.

Final Words

Diane’s trip to the hospital should have amounted to nothing more than a simple case of pneumonia that resulted in her walking out of the ICU no more than three days after admission.

Instead, she spent a total of 12 days in the ICU, deeply sedated and immobile for most of it, and as a result, she suffered unnecessarily.

If any member of this ICU team had spoken up and drawn attention to the risks of immobility and sedation, and the real focus of the ABCDEF Bundle, which is to keep patients awake, communicative, autonomous, and mobile, Diane would have been extubated on day two or three instead of day 10, and much of her suffering would have been avoided.

With that in mind, can we stop seeing this kind of inhumane and senseless treatment as normal?

Can we see our patients as humans and consider their lives as a whole?

Can we critically think through our interventions and use sedation as a high-risk tool only to be implemented when unavoidable?

And can we understand and practice early mobility as a life-saving treatment in the ICU?

I have great faith that humanizing the ICU and practicing safely and efficiently is within our reach.

If you and your team are ready to master the ABCDEF Bundle and create an Awake and Walking ICU, please don’t hesitate to sign up for a free consultation.

[daytonicuconsulting]

Prehab vs. Rehab: Which Approach Should be Prioritized in the ICU?

For the past five years, I have been engrossed in exploring the history and current culture of the ICU, as they relate to the ABCDEF Bundle.

As a result, I’ve been faced with having to compare my ingrained understanding of early mobility to the cultural “norms” I see at the bedside, as well as in the literature.

One of the key differences between these two perspectives, which I’ve been confronted with, is the timing and focus (or lack thereof) on early mobility in the ICU.

This contrast is captured in the comparison between prehab vs. rehab, and the debate about which approach should be prioritized in the ICU.

Prehab vs. Rehab: What’s the Difference?

If you want to understand the difference between prehab vs. rehab and learn which approach should be prioritized in the ICU, you’ve got to know what each one entails.

That being said, let’s explore the difference between prehabilitation and rehabilitation.

What Is Rehabilitation?

The Oxford Dictionary defines rehabilitation as “the action of restoring someone to health or normal life through training and therapy after illness.”

In the context of the ICU, the literature usually states that “Early rehabilitation is essential to reducing complications associated with PICS. ‘Early’ refers to rehabilitation interventions that commence immediately after stabilization of physiologic derangements, often while patients remain on mechanical ventilation and vasopressor infusions.”

And after years of attending conferences, visiting with dozens of ICU teams across the U.S., and reviewing their data and protocols, it is clear to me that rehabilitation in the ICU is perceived as the inevitable need for intensive physical recovery after mandatory and standard prolonged bed rest in the ICU.

But what we see in studies published within the last 6-8 years is that the “intensive rehabilitation” intervention groups did not even have patients sitting at the side of the bed until 8 or 9 days after intubation.

Even the recent TEAM study did not sit patients up at the side of the bed until 4-6 days after intubation following prolonged sedation at a median RASS of -3.

Yet the TEAM study is being hailed as the model of “ICU rehabilitation” and is considered an earlier and more aggressive level of rehabilitation than what you’ll find in most ICUs in the U.S.

What I’ve witnessed is that although many hospital protocols will allow for mobility to occur during critical illness, and while patients are on vasopressors, etc., it is not actually occurring in practice.

The approach shared by most of the ICU community is that mobility will happen when ventilator settings are minimal, when the patient follows commands, after extubation, after the tracheostomy, after vasopressors are discontinued, etc.

It seems as long as physical or occupational therapy consultation orders are entered before the patient transfers from the ICU, early mobility is checked off of the list as done.

But when you consider that on average, critically ill patients lose nearly 2% of skeletal muscle per day during their first week in the ICU, it’s clear that delaying mobility can lead to devastating consequences.

These consequences, including the loss of physical and cognitive function, result in a desperate need for ICU rehabilitation.

As a result, ICU rehab tends to be implemented as the recovery from delirium and ICU-acquired weakness on the back end of critical illness.

But what if we focused more on preventing delirium and ICU-acquired weakness?

What Is Prehabilitation?

Prehabilitation is defined as a process of improving the functional capability of a patient before a procedure or treatment so they’re able to withstand any inactivity and associated decline.

That being said, most patients do not anticipate sudden critical illness, so how does prehabilitation apply in the ICU?

In 2002, Robert Topp defined prehabilitation in the ICU as “The process of enhancing functional capacity of the individual to enable them to withstand the stressor of inactivity associated with an admission to ICU.”

A prehabilitative approach in the ICU respects the fact that patients arrive at the ICU with risk factors for delirium and ICU-acquired weakness and may have a long and complicated hospital stay ahead of them.

At this point, their physical, cognitive, and psychological function are already in peril and require proactive intervention focused on the preservation of functional capacities.

This leads ICU teams to promptly implement interventions to prevent delirium and ICU-acquired weakness, such as nutrition, early mobility, sleep hygiene, and family engagement.

For most patients, prioritizing prevention rather than recovery can drastically change the outcomes they experience.

For instance, the timing of early mobility impacts short and long-term outcomes for patients in the ICU.

A recent study showed that when early mobility happens within 72 hours of ICU admission there is a positive impact on post-ICU syndrome, but these benefits are limited if early mobility is initiated after 72 hours have passed.

Another study revealed that mobilizing patients within less than 72 hours after intubation led to a 24% improvement in return to functional baseline and a two-day decrease in delirium and time on the ventilator.

We also know that mobilizing patients within 48 hours after intubation improves cognitive function by 20% one year after discharge.

Prehabilitation in Practice

For the first eight years of my career, I was unfamiliar with the term ICU rehabilitation.

All I knew was that physical and occupational therapy are a standard part of care with the same priority as antibiotics, vasopressors, and AM labs. Walking my intubated patients on the night shift was just as optional as their bed bath.

The word rehabilitation usually only came up on the rare occasion when we were disappointed that we were sending a patient to a care facility instead of back home.

Our shared goal was to have patients walk out of the doors and avoid extensive rehab.

But when I started working in an Awake and Walking ICU, our patients were mobilized within 12 hours after intubation unless there was a contraindication to mobilization.

The decisions of whether or not to start sedation, what type of sedation to use, and whether or not to mobilize patients were esteemed as a “clinical priority on a par with early resuscitation, early sepsis management, and a lung-protective strategy.”

When the teams I train adapt this prehabilitative approach, they immediately notice the contrast in patient outcomes and workload.

What’s more, they enjoy being able to protect patients from the occurrence and severity of ICU delirium and ICU-acquired weakness, rather than having to rehabilitate patients after these complications have developed.

I trained Andrea Silva’s team in Denver, Colorado about a year ago, and they have transformed their process of care from a back-end rehabilitation approach to a front-end prehabilitation approach.

Here’s what she had to say about it:

“Prehabilitating patients in the ICU not only decreases length of stay, but it also reduces vent days and prevents delirium. There is a sense of nursing satisfaction and fulfillment when you see your patients thrive and walk out of the ICU.

“The morale around the unit has had a positive shift by seeing our patients succeed. We used to rehabilitate patients in the ICU by doing mobility after extubation, but our delirium rates were high, everyone had tracheostomies and PEG tubes, and they were waiting for placement in care facilities. Now patients are walking home from the ICU.”

So, what if prehabilitation becomes the norm?

What if it took 2-3 clinicians to walk an intubated patient down the hall rather than 3-5 people to sit a patient at the side of the bed?

What if we reduced delirium rates from where they are now, at 60-80%, and turned delirium into something that rarely occurs in the ICU?

What if we were able to enjoy calm, cooperative, and functional patients?

What if we shifted our focus to proactive instead of reactive?

And what if our efforts were dedicated to protection rather than recovery from delirium and ICU-acquired weakness?

If we were to do all of these things, I can only imagine how many lives would be saved and preserved, and the effect this could have on generations of ICU patients and clinicians to come.

If you and your team are ready to master the ABCDEF Bundle and create an Awake and Walking ICU, please don’t hesitate to sign up for a free consultation.

[daytonicuconsulting]

Why ICU Culture Is a Barrier to Early Mobility

While it’s clear that the ABCDEF Bundle saves lives and helps to restore the quality of life for ICU survivors, many intensive care units continue to standardize deep sedation and immobility.

But why is this?

Why does one ICU use sedation on less than 20% of intubated patients, while another sedates 100% of these patients into medically-induced comas?

And why do patients suddenly start mobilizing when they’re transferred to an ICU that prioritizes early mobility, even when their medical status has not changed?

With these questions in mind, it’s important to understand that ICU culture is one of the main barriers to creating Awake and Walking ICUs, which prioritize evidence-based practices like early mobility.

The Merriam-Webster dictionary defines culture as “a set of shared attitudes, values, goals, and practices that characterize an organization and shape the behavior of its members.”

Unfortunately, the outdated attitudes, values, goals, and practices of much of the ICU community are often exposed throughout the internet.

Decades of prevailing ICU culture, which prefers to keep ventilated patients comatose and immobile, is expressed, particularly through memes on social media, many of which have been shared tens of thousands of times.

Over 10 years ago, as a younger travel nurse, I too chuckled at jokes like these:

But what I didn’t know was that I was laughing at increasing patient death, suffering, and disability.

Unfortunately, it is memes like these that truly reveal the influence ICU culture has on bedside practices.

For instance, when I asked my Instagram followers if these “jokes” existed at the bedside in their ICUs, 94% of respondents said yes.

And when I asked if they believe that this influences practices at the bedside, 97% said yes.

All things considered, there’s no denying that ICU culture is a significant determinant of whether patients will be sedated and immobile or awake and ambulating.

However, the prevailing ICU culture of automatic and persistent sedation and immobility exists not because clinicians don’t want to provide the best care and outcomes for their patients, but because they don’t understand how these interventions affect patients during and after the ICU.

Knowledge Gaps in ICU Culture

One of the main reasons why ICU clinicians fail to create Awake and Walking ICUs is that they lack the knowledge required to understand the why and how of the ABCDEF Bundle.

With that in mind, here are some of the knowledge gaps in the ICU that are preventing the implementation of these evidence-based practices:

Sedation

Numerous gaps in education have molded ICU culture and, in turn, the beliefs and practices that it promotes.

One of the biggest gaps for ICU clinicians is their lack of understanding of the risks of sedation.

ICU clinicians are not taught the risks of sedation and instead are led to believe that patients are peacefully sleeping while they’re sedated.

For instance, a survey published in the American Journal of Critical Care found that 66% of ICU nurses believe sedatives are necessary for patient comfort.

Moreover, surveys have found that 59-77% of ICU clinicians would want to be sedated if they were intubated.

As you can tell, when clinicians are not exposed to the survivor perspective and fail to understand the increased risk of death, brain injury, trauma, and disability that comes with prolonged sedation, the myths that sedation is “sleep” and “humane” continue.

This misunderstanding acts as a justification and can increase clinicians’ personal preference for sedation and influence how they sedate their patients.

And because sedation is seen as benign, jokes are often made about it, both on and off the unit.

Sadly, most ICU clinicians are unaware that what they’re actually joking about is the increased suffering and death that their patients have to endure.

https://www.youtube.com/embed/F8093Ppvf7g

This false narrative that patients are comfortable under sedation is then reinforced by what ICU clinicians witness when sedation is turned off and patients emerge from the depths of delirium suffering from agitation and terror.

When nurses resume sedation, patients return to being motionless and they feel they have “fixed the problem” by “returning patients to their slumber.”

But until clinicians understand the torture patients endure while sedated, they will continue to think this “humane approach” is something to be laughed at in memes and perpetuated at the bedside.

What’s more, having to deal with caring for these patients after causing delirium with sedation reinforces the idea that the ABCDEF Bundle is impossible to implement because it is “too much work.”

Ironically, it’s the failure to implement these protocols that’s making everything more difficult, as delirium doubles the nursing hours required for care, increases workplace violence, and causes a significant psychological burden for nurses.

But regardless of what the truth may be, when clinicians see the ABCDEF Bundle as extra work, it is less likely to be adapted into ICU patient care.

The reality is until clinicians have the knowledge and support required to prevent and treat delirium, transform patient outcomes, and reduce their workload, it’s unlikely they will ever be empowered or motivated to ensure their patients are awake and mobile.

And when clinicians are deprived of the ability to master these evidence-based practices and truly prevent ICU delirium and ICU-acquired weakness, they continue to suffer from a heavier workload.

But when they adhere to the protocols found in the ABCDEF Bundle, their workload will be lightened, as they’ll be dealing with patients who are more likely to be strong, awake, compliant, and pleasant.

Mobility

Across all disciplines, from physicians and nurses to physical, occupational, and respiratory therapists, early mobility in the ICU is not a standard part of their education.

As a result, one of the barriers to early mobility is that many nurses believe their patients are “too sick” to mobilize, as is reflected in this meme:

At the same time, physical and occupational therapists may not have the training and experience to mobilize high-acuity intubated patients with ventilators, and respiratory therapists may be overcome with fear of an endotracheal tube falling out during mobility.

Physicians, on the other hand, may think early mobility is simply passive range of motion and higher levels of mobility are only important after extubation.

But ultimately, until every member of the ICU team understands that early mobility is feasible and safe during critical illness, and has a shared perspective on inclusion criteria, mobility will always be perceived as a scary and seemingly unachievable ideal.

Punitive Safety Culture

In a misguided effort to increase patient safety, a punitive culture has been developing in critical care medicine throughout the years.

Nurses are held solely liable for safety events like falls and unplanned extubations, and this has led to increased sedation, restraints, and confining patients to the bed in the name of “safety.”

Instead of fearing delirium and ICU-acquired weakness, which we know lead to self-extubationsand falls in the ICU, nurses are led to believe that patients are “safe” when comatose and strapped to a bed for their entire shift.

The result of all this is that nurses believe their licenses and employment are in jeopardy if patients are awake enough to move or are anywhere but in bed.

However, the truth is that evidence-based practices, like early mobility and cessation of sedation, offer some of the best ways of preventing delirium and ICU-acquired weakness, which can decrease the risk of falls, unplanned extubations, and even violence against health care workers.

When clinicians experience the impact that these protocols have on their workload, safety, and the safety of their patients, they quickly begin to understand that the ABCDEF Bundle brings true safety for everyone, both in the short and long term.

The bottom line is that until clinicians feel empowered and psychologically safe to liberate their patients from sedation, restraints, and the bed, critical care culture cannot transform.

If clinicians aren’t being rewarded for adhering to best practices and protected from a punitive administration, they will continue to choose interventions that allow them control and “safety” during their shift, and it will become increasingly difficult to create Awake and Walking ICUs.

Accountability

Transforming ICU culture and practices requires consistent accountability.

For example, trying to ensure that documentation is accurate can be an incredible challenge.

The current culture in many ICUs encourages poor oversight and low accuracy when screening for delirium and mobility, performing awakening trials, and ensuring reliable RASS scores.

One study showed that despite sedation orders for a RASS 0-(-3), 70% of patients were sedated to a level of -4 and -5, regardless of documented RASS scores of -3 or higher.

Unfortunately, most clinicians don’t know that deep sedation is an independent predictor of mortality and they’re typically not supported in monitoring sedation levels.

Moreover, most clinicians are unaware that a lack of ICU mobility is also an independent predictor of mortality.

It is not standard practice in most ICUs to collaboratively weigh the risks versus the benefits of early mobility, but if early mobility were seen as the life-saving intervention it is, then it would be treated like an antibiotic and never missed.

Yet in most ICUs it is acceptable to chart “bed rest” as a default for all intubated patients as mobility screening.

This causes patients who should be mobilized to easily fall through the cracks, as there is very little oversight for which patients actually have a contraindication to mobility and which patients should be promptly mobilized.

That being said, until the ABCDEF Bundle is implemented, and there is true stewardship and accountability for what’s documented in the ICU, intubated patients will continue to be automatically put on bed rest, and both they and the clinicians who care for them will have to deal with the consequences.

Lack of Interdisciplinary Collaboration

The ABCDEF Bundle is like a team sport – without proper team dynamics, it’s impossible to properly implement these protocols and create Awake and Walking ICUs.

With that in mind, here are some of the interdisciplinary barriers I’ve witnessed in the ICU:

Toxic Hierarchy

When an ICU team has a culture in which physicians are the only decision-makers, idea-generators, and solution-contributors, the entire team suffers.

The ABCDEF Bundle requires that the ICU be a safe place for each member of every discipline to offer insights and ideas that are respected, embraced, and adapted by the entire team.

Each professional is valued and invited to share their expertise.

But when any member of an ICU team feels they have gained all the knowledge they possibly can, and consider themselves an absolute expert, they become impermeable to new information.

They remain unmovable in the practices that are familiar and comfortable to them, and they’re resistant to change and evolution.

Fight for Control

Nurses should not be the only decision-makers when it comes to sedation and mobility practices.

Physicians, respiratory therapists, physical therapists, and all other relevant disciplines must discuss sedation, delirium, and mobility interventions together.

Because when nurses restrict their colleagues from having access to their patients, they also deprive themselves of invaluable assistance with managing things like patient anxiety, delirium, and mobility, which can further exacerbate poor patient outcomes and burdens on nurses.

Interdisciplinary Appreciation

It is key for every member of an ICU team to recognize the value and expertise of their colleagues.

For instance, as nurses and respiratory therapists come to understand, witness, and appreciate the expertise rehab clinicians bring to their patients, they can develop trust and relationships that help optimize patient care and outcomes.

What’s more, when physicians see the safety and skill with which their colleagues handle high-acuity patients, they will be quicker to consult them early on in patients’ critical illness.

Dehumanization

After decades of normalizing constant sedation and immobility, culture in the ICU can easily become dehumanized.

For one thing, when patients are comatose and unresponsive, it’s almost impossible to have a deep human connection with them.

https://youtube.com/embed/iPyVk0B3TdQ.

This false narrative that patients are comfortable under sedation is then reinforced by what ICU clinicians witness when sedation is turned off and patients emerge from the depths of delirium suffering from agitation and terror.

And because clinicians constantly face traumatic and devastating situations in the ICU, ICU culture often teaches us to become “hardened” to protect ourselves from feeling anything that could lead to sadness or burnout.

This emotional distance and posturing can have a decidedly negative impact on an ICU team’s ability to achieve the objective of the ABCDEF Bundle, which is to “produce patients who are more awake, cognitively engaged, and physically active, which ultimately serves to facilitate patient autonomy and the ability to express unmet physical, emotional, and spiritual needs.”

In other words, it is not the culture of most ICUs to want patients to be awake and communicative.

And until ICU clinicians can continually experience the joy of deep connection and communication with their patients, they will never expect this to be the norm:

Ultimately, a RASS score of 0 should be our true goal for most patients in the ICU.

But until we shift ICU culture to look at the patient as an autonomous being who should be awake, communicating, and engaged, with few exceptions, we will not shift our sedation and mobility practices to align with the ABCDEF Bundle.

Final Words

As an ICU revolutionist, you shouldn’t have to endure such challenging dynamics and moral injury when all you’re trying to do is advocate for the use of best practices for your patients.

Luckily, when the rest of your colleagues receive the key foundational knowledge that’s required to understand the risks and costs of sedation and immobility, they will be much more open to new skills, dynamics, and relationships that will help transform sedation and mobility practices.

As an ICU consultant who helps clinicians create Awake and Walking ICUs, some of my favorite feedback from ICU teams, following their evolution, has been:

“This is so much easier!”

“We’re finally working together as a team.”

“I am really enjoying my new friendships with my PTs, OTs, RTs, etc.”

“The morale of the unit has really changed since we’ve started having a lot of patient success. We can see that we’re saving lives and we’re celebrating together.”

If your team is ready to overhaul its culture and practices, please don’t hesitate to sign up for a free consultation.

[daytonicuconsulting]

Sedation by Race: How Outdated ICU Practices Are Exacerbating Health Care Inequality for Hispanic Patients

Health care inequality in critical care medicine is multifactorial and negatively impacts patient outcomes [18].

During COVID-19, for instance, it was noted that Hispanic patients were more at risk of having severe COVID-19 infections, and despite their younger age, they had a higher mortality rate.

Socioeconomic disparities, lack of access to health care, timing, and quality of care all play a part in the contrast in outcomes for Hispanic patients in the ICU [14], and outdated sedation practices in the ICU are causing greater inequality in and after the ICU for Hispanic patients.

Fortunately, the ABCDEF Bundle has the power to decrease seven-day mortality by 68% [12], but compliance with the ABCDEF Bundle tends to be lower when it comes to the care Hispanic patients receive.

And although delirium doubles the risk of dying in the hospital, [15], Hispanic patients have half the odds of having delirium assessments performed when compared to non-Hispanic patients [5].

What’s more, benzodiazepines are known to increase ventilator-associated pneumonia, time on the ventilator and in the hospital, and they can also increase delirium [19] and mortality by about 20% [7]. However, during COVID-19, Hispanics were more likely to receive benzodiazepines than non-Hispanic patients [20].

But the health care inequality that we see in sedation practices is not unique to COVID-19.

A secondary analysis of data from the ROSE study [9], which evaluated the care of patients with ARDS during 2016-2018 revealed shocking revelations.

For example, despite deep sedation being an independent predictor of death [17], Hispanic patients were 5 times more likely to be deeply sedated than non-Hispanic patients [2], and the failure to practice the ABCDEF Bundle may be a significant contributing factor to the 44% increased mortality rate among Hispanic COVID-19 patients when compared to non-Hispanic White patients [14].

Sedation practices in the ICU can also exacerbate socioeconomic and health care inequality long after the ICU, not least because deep sedation is independently associated with delirium [13].

Delirium increases the risks of long-term cognitive impairments by 120 times [6] and increases the rate and severity of post-ICU PTSD [16]. These post-ICU cognitive and psychological impairments can have devastating impacts on employment and quality of life after a patient leaves the ICU.

The reality is 49% of patients who have suffered from ICU delirium are still newly unemployed 12 months after discharge [11].

What’s more, access to cognitive, physical, and psychological rehabilitation after the ICU may be limited for Hispanic ICU survivors, and financial support may be limited if they become disabled.

What’s Causing This Health Care Inequality for Hispanic Patients?

In Episode 115 of my Walking Home From The ICU podcast [4], Dr. Thomas Valley discusses the findings of his study that revealed the lethal disparities in sedation practices among Hispanic patients even before COVID-19 [2].

He speculated that a language barrier may lead to higher levels of sedation and the inability to screen for delirium, as many Hispanic patients may not speak English and do not have a way to understand and communicate with their health care providers.

This inability to report pain, needs, wants, and concerns, and to have questions addressed, can escalate anxiety and agitation, influencing clinicians to continue and even increase sedation.

Nurses have reported that their primary method of non-verbal communication in the ICU with intubated patients is reading patients’ lips, thumbs up or down, and head nodding [1], mainly because their health system fails to provide evidence-based resources or education on best practices and despite four decades of research reporting these methods are wrought with error and are ineffective [21].

Inadequate for most patients, these methods are simply not feasible options for patients who do not understand or speak English, and the inability to communicate when critically ill can have deadly repercussions.

It’s been shown, for instance, that problems with communication in the ICU can cause a threefold increased risk of having an adverse event and can also make patients 26% more likely to suffer multiple adverse events [3].

Communication is a basic human right [8], and the lack of ICU communication solutions for all patients, regardless of race, language, and ability to verbalize is a human rights violation that exacerbates racial disparities in health care and worsens outcomes in the ICU.

To not pursue all means to establish effective communication for these patients is no less neglectful than to leave a patient febrile or hypotensive.

That being said, while there may have been a rationale for ineffective ICU communication to be the expected norm for intubated patients three or four decades ago, we now know how to address this issue, and not addressing it with an evidence-based approach, like the one provided by the ABCDEF Bundle, is nothing short of neglect.

The ABCDEF Bundle is the roadmap to saving and preserving lives for all patients, regardless of race, during and after the ICU.

The goal of this approach is “to produce patients who are more awake, cognitively engaged, and physically active” [12] and to “facilitate patient autonomy and the ability to express unmet physical, emotional, and spiritual needs.”

It is impossible to fully optimize and apply the ABCDEF Bundle if access to communication is not available for each patient in their own language.

Bridging the ICU communication gap will help bring better equity to care and outcomes for Hispanic patients. And if you want to reduce sedation exposure, start by reducing the need for it by ensuring intubated patients are communicating effectively.

VidaTalk Offers a Solution

For many patients, having access to communication with health care providers can be the difference between life and death.

Being able to effectively communicate allows them to understand their situation, be informed and empowered to make decisions for their care, and have pain and anxiety adequately treated.

At the same time, it also enables them to be awake and mobile while intubated, which can drastically improve their opportunity to survive and thrive both during and after the ICU.

With that in mind, I am ecstatic to share a solution to this problem in the form of a software tool called VidaTalk.

VidaTalk is the only tool that provides non-verbal communication for intubated patients in over 40 different languages [10].

If your team is interested in providing more equitable, ethical, and humane practices in your ICU, Dayton ICU Consulting and VidaTalk are ready to help.

For a free demo of VidaTalk and consultation with Dayton ICU Consulting, email [email protected] or schedule a free consultation today.

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References:

Al-Yahyai, R., Arulappan, R., & Matua, G.A., et al. (2021). Communicating to Non-Speaking Critically Ill Patients: Augmentative and Alternative Communication Technique as an Essential Strategy. SAGE Open Nursing, 7.

Armstrong-Hough, M., Lin, P., Venkatesh, S., Ghous, M., Hough, C. L., Cook, S. H., Iwashyna, T. J., & Valley, T. S. (2024). Ethnic Disparities in Deep Sedation of Patients with Acute Respiratory Distress Syndrome in the United States: Secondary Analysis of a Multicenter Randomized Trial. Annals of the American Thoracic Society, Advance online publication.

Bartlett, G., Blais, R., Tamblyn, R., Clermont, R. J., & MacGibbon, B. (2008). Impact of patient communication problems on the risk of preventable adverse events in acute care settings. Canadian Medical Association Journal, 178(12), 1555–1562.

Dayton, K. (2022). Episode 115: Sedation By Race. Walking Home From The ICU.

DeMellow, J. M., Kim, T. Y., Romano, P. S., Drake, C., & Balas, M. C. (2020). Factors associated with ABCDE bundle adherence in critically ill adults requiring mechanical ventilation: An observational design. Intensive and Critical Care Nursing, 60, 102873.

Dziegielewski, C., et al. (2021). Delirium and associated length of stay and costs in critically ill patients. Critical Care Research and Practice.

Lee, H., Choi, S., Jang, E. J., Lee, J., Kim, D., Yoo, S., Oh, S. Y., & Ryu, H. G. (2021). Effect of Sedatives on In-hospital and Long-term Mortality of Critically Ill Patients Requiring Extended Mechanical Ventilation for ≥ 48 Hours. Journal of Korean Medical Science, 36(34), e221.

Mcleod, S. (2018). Communication rights: Fundamental human rights for all. International Journal of Speech-Language Pathology, 20(1), 3–11.

The National Heart, Lung, and Blood Institute PETAL Clinical Trials Network. (2019). Early Neuromuscular Blockade in the Acute Respiratory Distress Syndrome. New England Journal of Medicine, 380(21), 1997–2008.

News – Vidatak. https://vidatak.com/ (n.d.)

Norman, B. C., Jackson, J. C., Graves, J. A., Girard, T. D., Pandharipande, P. P., Brummel, N. E., Wang, L., Thompson, J. L., Chandrasekhar, R., & Ely, E. W. (2016). Employment Outcomes After Critical Illness: An Analysis of the Bringing to Light the Risk Factors and Incidence of Neuropsychological Dysfunction in ICU Survivors Cohort. Critical Care Medicine, 44(11), 2003–2009.

Ely, E. W., et al. (2019). Caring for Critically Ill Patients with the ABCDEF Bundle: Results of the ICU Liberation Collaborative in Over 15,000 Adults. Critical Care Medicine, 47(1), 3–14.

Rasulo, F. A., Badenes, R., Longhitano, Y., Racca, F., Zanza, C., Marchesi, M., Piva, S., Beretta, S., Nocivelli, G. P., Matta, B., Cunningham, D., Cattaneo, S., Savioli, G., Franceschi, F., Robba, C., & Latronico, N. (2022). Excessive Sedation as a Risk Factor for Delirium: A Comparison between Two Cohorts of ARDS Critically Ill Patients with and without COVID-19. Life, 12(12), 2031.

Ricardo, A. C., Chen, J., Toth-Manikowski, S. M., Meza, N., Joo, M., Gupta, S., et al. (2022). Hispanic ethnicity and mortality among critically ill patients with COVID-19. PLoS ONE, 17(5), e0268022.

Salluh, J., et al. (2015). Outcome of delirium in critically ill patients: systematic review and meta-analysis. British Medical Journal, 350.

Schelling, G., Stoll, C., Haller, M., Briegel, J., Manert, W., Hummel, T., Lenhart, A., Heyduck, M., Polasek, J., Meier, M., Preuss, U., Bullinger, M., Schüffel, W., & Peter, K. (1998). Health-related quality of life and posttraumatic stress disorder in survivors of the acute respiratory distress syndrome. Critical Care Medicine, 26(4), 651–659.

Shehabi, Y., Bellomo, R., Reade, M. C., Bailey, M., Bass, F., Howe, B., McArthur, C., Seppelt, I. M., Webb, S., Weisbrodt, L., Sedation Practice in Intensive Care Evaluation (SPICE) Study Investigators, & ANZICS Clinical Trials Group (2012). Early Intensive Care Sedation Predicts Long-Term Mortality in Ventilated Critically Ill Patients. American Journal of Respiratory and Critical Care Medicine, 186(8), 724–731.

Soto, G. J., Martin, G. S., & Gong, M. N. (2013). Healthcare Disparities in Critical Illness. Critical Care Medicine, 41(12), 2784–2793.

Spiegler, P. (2014). Benzodiazepines in the ICU: Enough Is Enough!. Clinical Pulmonary Medicine, 21(6), 288–289.

Valley, T. S., Iwashyna, T. J., Cook, S., Hough, C. L., & Armstrong-Hough, M. (2021). Associations Among Patient Race, Sedation Practices, and Mortality in a Large Multi-Center Registry of COVID-19 Patients. American Journal of Respiratory and Critical Care Medicine, 203(9).

Happ, M. B. (2021). Giving Voice: Nurse-Patient Communication in the Intensive Care Unit. American Journal of Critical Care, 30(4), 256–265.

[daytonicuconsulting]

How the ABCDEF Bundle Can Help Mitigate RN Burnout

Nurses enter critical care medicine to alleviate human suffering, support patients in their most vulnerable moments, be patient advocates, do no harm, and save lives.

But being a critical care nurse is physically, emotionally, and mentally challenging.

Many factors have resulted in the loss of thousands of expert nurses, creating the staffing crisis we’re currently facing.

Poor support for nurses, lack of career fulfillment, moral injury [18], high emotional exhaustion, and low personal accomplishment [33] all contribute to RN burnout.

Moreover, the current practice of automatic sedation and immobility for every intubated patient has exacerbated the challenge of keeping ICU nurses at the bedside, ultimately increasing RN burnout through increased workload, less team support, and poor patient outcomes.

Other side effects of these outdated practices, such as high rates of delirium and ICU-acquired weakness, are also worsening the nursing crisis.

But now that we have the ABCDEF Bundle, there is no reason for things to continue this way.

The ABCDEF Bundle [35] is a readily available toolkit to help guide clinicians on how to use evidence-based sedation and mobility practices.

Failing to put these practices in place deprives nurses of accomplishing their mission and having the satisfaction of watching their patients have the best outcomes, and I’ve experienced this firsthand.

I started my nursing career in an Awake and Walking ICU, where nearly all patients were awake after intubation and doing their highest level of mobility shortly thereafter.

But after a few years, I started working as a travel nurse and was shocked to find that this was not standard practice throughout the nine other ICUs I worked in.

I was losing my love of nursing and briefly considered leaving the field.

When I returned to the Awake and Walking ICU, I realized that my job was far more fulfilling and manageable because of the changes in the use of sedation and increased mobility afforded by the protocols outlined in the ABCDEF Bundle.

These evidence-based practices helped preserve my patients’ mental and physical capabilities, which reduced their delirium, decreased their length of stay, and increased their participation in their care.

Keep reading if you want to learn more about how these protocols can help to mitigate RN burnout.

But before I continue, I want to give a special thank you to all the ICU nurses who contributed to this article, including Roni Kelsey, Jessica Williams, Liz McQueen, Richard Woods, Tara Arroyo, James Fletcher, Allison Diburro, Tara Dagesse, Sarah Vance, Sean Karbach, Annie, and those who chose to be anonymous.

Delirium and RN Burnout

Delirium is a life-threatening brain dysfunction that increases the psychological burden, risks, liabilities, and staffing demands on nurses [36].

Nurses report high emotional stress, strain [23], and burden [25] when caring for patients with delirium.

Protecting and monitoring patients who are confused, scared, combative, and impulsive during hyperactive delirium is a significant challenge for nurses, and the responsibility to keep patients safe with their lines and tubes intact can be a heavy burden.

Yet they are forced to work in an environment that leaves both patients and nurses vulnerable to the complications of delirium.

Delirium is at the root of many adverse events in the ICU.

For instance, delirium increases the risks of unplanned extubation by 11.6 times [24] and increases the risk of all line and tube removals [42].

The sooner my ICU patients are sedation-free, honestly, the easier my job is to care for them. Even intubated, they are better about caring for themselves, communicating their needs, and they end up protecting their ET tube. − Richard Woods, Utah                                                        

Over 50% of falls in the ICU occur in the setting of delirium, delirium increases the risk of falls by 3.85 times [26], and previous sedation and analgesia infusions increase the risk of falls by 60% [45].

Deep sedation is also an independent predictor of mortality and delirium, as it doubles the risk of dying in the hospital [34], and for every one day of delirium there is a 10% increased risk of death [15].

What’s more, delirium not only increases harm to patients, but also increases the amount of violence nurses [21] have to endure, causing them to fear for their safety and suffer from diminished self-esteem and inner conflicts.

Delirium also increases time in the ICU on average by 4.47 days and 6.67 in the hospital [12], doubles the nursing hours required for care [38], contributes to difficulty interpreting patients’ needs, and can increase nurse discomfort [39].

Caring for delirious patients also contributes to nurse burden [2], and delirium severity is actually a predictor of nurse distress [4].

Caring for another human that you just met takes a special kind of energy. But to care for a confused and combative stranger that you are also tasked with keeping safe is even more stressful and requires even more time and energy. − Roni Kelsey, Washington

Hypoactive delirium can be “safer” and “easier” to manage, but patients depend on nurses for turning, toileting, bathing, and nutrition.

In any case, when patients suffer from delirium, nurses lose the opportunity to have calm, compliant, awake, and engaged patients. They are deprived of connection and communication with those they work diligently to serve.

I honestly think losing that connection with patients during COVID was the hardest part for me. I lost a huge portion of the most satisfying part of my job and it hurt. − Tara Arroyo, Salt Lake City, Utah

When patients are sedated for prolonged periods of time, the burden falls on their nurses, who must do the awakening trial to unmask the delirium and agitation the patient is suffering from under sedation.

Nurses are held liable for unplanned extubations and yet they are often left alone with confused, scared, and hyperactive patients. This increases risks for nurses and patients and can contribute to RN stress and exhaustion.

Moreover, nurses are challenged and expected to perform all elements of care from medication passes to activities of daily living, all while patients are unable to participate in their care or voice concerns when heavily sedated and faced with an increased risk of having poor outcomes.

Watching patients suffer and then die despite great effort and care comes at a high price for nurses.

I extubated a patient and transferred them to the floor. I lost it and started crying. I realized at that moment that it had been so long since I had extubated a patient and they got better. − Liz McQueen, Colorado [7]

ICU-Acquired Weakness and RN Burnout

ICU-acquired weakness is the devastating loss of muscle mass and function that occurs in 50% of patients in the ICU [5]. It results in significant limb weakness and is associated with diaphragm atrophy and dysfunction.

This dangerous and burdensome condition rapidly develops as patients can lose 40% of lean muscle mass within one week of bedrest [43].

ICU-acquired weakness leads to more time on the ventilator and in the ICU, higher rates of hospital-acquired infections, and poor outcomes for patients.

The profound loss of physical function and prolonged time in the ICU increases the demand for nurses as patients become dependent on total care. ICU-acquired weakness also increases failure to wean from the ventilator by 15.4 times and time on the ventilator by 20 days in sepsis patients [17].

Patients who develop ICU-acquired weakness also require more nurses and ICU staff to initiate mobility.

Here’s what Tara Dagesse, an ICU nurse from Connecticut, shared about caring for patients with ICU-acquired weakness:

I cared for a VV ECMO patient who had a severe ICU-acquired illness from sedation and immobilization practices at a former hospital. They had been extubated but were previously on heavy sedation.

I organized to get this patient hovered to a chair and set them up with bicycle pedals. I did this when other colleagues were available to help with lines, tubes, and wires during the hover, but the rest I did on my own. I hadn’t consumed much water that day because the break room was far from the patient’s room; I actually went to my own emergency department after my shift for a kidney stone from the lack of access to drinking water during that shift.

It had taken such significant effort and organization because of the patient’s severe neurologic and physical disability from the sedating medications that we gave them. Their lungs were recovering via the ECMO, but we irreparably damaged this person’s brain and body from sedation in the process.

It is not an easy task to mobilize such a patient, and even though I was determined, organized, and motivated, I ended up having to put my own basic human needs last to provide what I felt was a successful physical therapy day for my severely debilitated patient. 

I was proud of the result for the patient, but I was unsustainably fighting the impenetrable heavy sedation culture. I had little support for my patients to be successful and have good outcomes from that program, and the oversedation culture directly affected my mental health. 

When we would eventually have patients awaken, they had ‘dead eyes’ and were fully dissociated or otherwise neurologically withdrawn from the lasting effects of the continuous heavy sedation.

Families don’t question the need for sedation because ‘they seem comfortable,’ but this was an unfulfilling way to practice nursing. I did not go into this field to harm patients and that’s exactly what we were doing. I considered leaving nursing altogether like so many of my colleagues because I was told ‘the grass isn’t always greener.’

I eventually left that ICU after realizing I could no longer ethically care for patients in that environment.

I now work for a different hospital with better working conditions and unit-wide support for limiting sedation and keeping patients awake and active on the ventilators so they can be part of their own care and interact with their families.

It’s much more rewarding and exciting to care for critically ill patients that actually get better because we utilize the ABCDEF Bundle as it was intended.

RN Burnout and the ABCDEF Bundle

Despite the challenges that delirium and ICU-acquired weakness pose for nurses and patients, the prevailing ICU culture of automatic sedation and immobility drastically increases the risks of these conditions.

Mechanical ventilation is not an independent indication for continuous sedation [14], yet in most ICUs, sedative drips are routinely started after intubation on all patients.

Sedation increases the risk of delirium by 2.268 times [30] and the severity of delirium [29]. In one study, patients who were free of sedation spent 4.2 fewer days on mechanical ventilation and 3.67-9.09 fewer days in the ICU than those who received interrupted sedation [40].

Sedation also causes the quickest and highest rates of muscle loss compared to other causes of muscular atrophy [31].

Nurses have the burden of keeping patients safe from adverse events such as falls and unplanned extubations. However, nurses are also trained to increase and prolong the use of sedation, which ultimately exacerbates delirium and ICU-acquired weakness, increasing these adverse events and the demand for nurses to provide total care.

The ABCDEF Bundle guides ICU teams to avoid sedation, provide prompt mobility, and protect patients and nurses from the risks and burdens of delirium and ICU-acquired weakness using the following tools:

A: Assess, Prevent, and Manage Pain B: Both Spontaneous Awakening Trials (SATs) and Spontaneous Breathing Trials (SBTs) C: Choice of Analgesia and Sedation D: Delirium: Assess, Prevent, and Manage E: Early Mobility and Exercise F: Family Engagement and Empowerment

A large study found that, on average, the ABCDEF Bundle decreased delirium by 25-50%, time on the ventilator and physical restraint use by 60%, 7-day mortality by 68%, discharges to anywhere but home by 36%, and readmission to the ICU by 46% [32].

Another study showed that ambulating patients within 36 hours after intubation increased their return to baseline functional status by 24% and decreased the duration of delirium by two days [37].

It’s also been shown that every additional 10 minutes of physical or occupational therapy decreases time in the hospital by 1.19 days [22].

At this point, it’s important to note that the ABCDEF Bundle requires interdisciplinary teamwork from physical therapists, occupational therapists, pharmacists, primary physicians, bedside nurses, respiratory therapists, and family to foster this all-encompassing, patient-centered approach [1].

The ABCDEF Bundle also fosters more team collaboration and improves the workplace environment. For example, one of the key tenets of these practices is mobility, which is a powerful tool for preventing and treating delirium and ICU-acquired weakness.

However, when patients are sedated, physical and occupational therapists are unable to provide meaningful therapy.

The main barriers to early mobility are sedation and agitation [41], which often leave nurses to struggle with agitated, delirious, and deconditioned patients by themselves.

But by allowing all disciplines to work together early on in an ICU admission to keep patients awake and mobile, most patients can remain cognitively and physically intact, which allows for more engagement in turning, mobility, and the care process in general.

Overall, as patients preserve their muscle mass and function at higher rates, less staff and equipment are likely to be required for mobility, and patients are likely to be liberated from the ventilator and transferred from the ICU far sooner.

This kind of collaboration, and the ability to ease workload offered by the ABCDEF Bundle, is demonstrated in the following case study:

A 32-year-old male patient with a history of obesity and polysubstance abuse was admitted to the ICU due to fentanyl overdose and aspiration pneumonia. He was intubated in the ICU and required a PEEP of 16 and 100%. A propofol intravenous drip was initiated at 30 mcg/kg/min. He became agitated and his propofol was then increased to 50 mcg/kg/min and he received midazolam pushes overnight.

The next day, the ICU team collaborated to investigate this patient’s condition and needs through the lens of the ABCDEF Bundle. As a result, it was realized that his agitation may be rooted in opioid and benzodiazepine withdrawal.

Enteral doses of opioid and benzodiazepine were given and propofol was discontinued. Six hours later, the patient was awake. He was given a whiteboard to write with and he remained awake but anxious at a RASS of +1 and CAM negative. While in bed, his oxygen saturations remained between 89% and 90%.      

The following morning, the patient sat himself at the side of the bed with physical and occupational therapy. His oxygen saturations immediately increased to 93% while on a PEEP of 16 and 100%.

His anxiety and tension dissipated and he got himself to the bedside chair with the minimal assistance of line and tube management. He spent most of the day in the chair free of restraints and sedation at a RASS of 0 during the following three days before being successfully extubated. He was independently walking around the ICU and transferred from the ICU shortly after.

Unfortunately, the reality is that without utilizing the ABCDEF Bundle approach, this patient likely would have remained on high-dose propofol and would have been at high risk of delirium and ICU-acquired weakness.

The nurses attending to him would have also been saddled with the risks and challenges of turning a 350-pound flaccid body for days or even weeks.

His muscle loss from myotoxic propofol [46] and immobility would have led to severe and prolonged dependence on the ventilator and nursing staff. Delirium he would likely experience could result in agitation, failed awakening trials, more stress and monitoring, and days to weeks longer in the ICU.

The challenging irony is that although adequate ICU staffing ratios are required to practice the ABCDEF Bundle [3], failing to practice it puts even more strain on staffing ratios through increased time on the ventilator, time in the hospital, manpower to care for patients, readmissions to the ICU and hospital, health care costs, and the burnout of nurses.

All things considered, one of the most powerful tools to prevent and treat delirium and ICU-acquired weakness is mobility.

Because of this, many nurses are expected to mobilize critically ill patients, but unfortunately, they are often untrained and unsupported in mobilizing them.

This leaves nurses with the burden of continuing to provide exhaustive total care and monitoring to confused and deconditioned patients for prolonged periods of time without the ability to truly treat and resolve delirium and ICU-acquired weakness.

Luckily, the ABCDEF Bundle offers one of the most effective ways to advocate for adequate staffing ratios, as delirium increases hospitalization costs by 39% [27], ICU-acquired weakness increases costs by 30.5% [19], and the ABCDEF Bundle can also decrease health care costs by at least 30% [20].

A nurse-led early mobility initiative in a medical ICU resulted in a 57% decrease in mortality, a 33% decrease in time on the ventilator, and was projected to have saved $2,070,000 that year [13].

Another ICU found their nursing-led mobility initiative increased mobility by 43% and resulted in a 50-100% decrease in hospital-acquired complications [44].

These stats are useless if the resources needed to mobilize patients are not available to nurses. I don’t doubt their efficacy − but most ICUs just do not have the resources (specifically staff) to safely mobilize their patients. 

Why is this? We would never deprive surgeons of soap and water to scrub with before surgery, as we have data that clearly shows the benefits of hand hygiene for infection prevention. If we have data that shows early mobilization in the intensive care setting results in better patient outcomes, why then do hospitals deprive their staff of the resources they need to provide their patients with high quality care? − Allison Diburro, Massachusetts

Still, the fact is many nurses may be unaware of the increased burden of sedation and immobility, and what is “normal” and familiar is often comfortable and accepted as unavoidable.

These practices may even be preferred, but nonetheless, even when unaware of the risks of these interventions, nurses are subjected to dealing with the psychological toll of seeing frequently poor outcomes for their patients.

Patient autonomy and nonmaleficence are core principles of nursing ethics [16], but sedation deprives patients of their voice and their autonomy.

Depriving patients of the ability to participate in end-of-life decision making can lead to prolonged treatments and severe ethical turmoil for nurses.

Nurses often struggle with the idea of providing treatments that they perceive as prolonging suffering or doing harm to patients [28].

We used to do things for patients and now we do things to patients. I used to leave work and had a sense that I made a difference. I missed time from family and friends for a reason, but now I have those moments less and less. We have the technology to do more and so we do more for a prolonged amount of time and we start to see the slow decline of a human into a failing body.

When you add sedation, you remove the patient’s voice, and delirium amplifies this tenfold. The patient can no longer advocate for themselves and families are left in moral distress deciding what to do. − Roni Kelsey, Washington

Nurses that know the harm of sedation and immobility, but lack support from their teams, face unbearable moral injury when unable to provide optimal evidence-based care for their patients.

They are forced to witness and struggle to treat the often preventable harm of delirium and ICU-acquired weakness [10], and when they know the life-long damages and increased mortality survivors will face from these conditions after the ICU, they are left with severe ethical turmoil [6].

I left my critical care training position due to a toxic work culture and my own moral distress of watching patient after patient be put on a pathway to delirium.

My introduction to the ABCDEF Bundle occurred on the final day of didactic training. The only motivation provided for adhering to the bundle was that we had to demonstrate proper charting of the elements or else face consequences – there was no explanation of the inherent purpose or value of the bundle itself.

In practice, I observed patients appearing significantly oversedated, with RASS assessments that seemed inconsistent with the clinical presentation. Spontaneous awakening trials were attempted sporadically and incompletely. When I raised concerns regarding these issues, the responses typically referenced patient comfort, with explanations such as ‘it’s not nice to have a tube down your throat’ and ‘the patient needs to sleep.’ Potential consequences of oversedation, such as delirium or delayed weaning, were not discussed. 

I went into the ICU excited about being challenged with complex medical puzzles. But in the end, the moral distress of putting patients down the path of deconditioning, oversedation, delirium, and long-term consequences, such as permanent disability, was too great for me to participate any longer. − Annie, California

I often shared awake and walking concepts with my coworkers and attempted to convince others to remove restraints, use other forms of treatment for agitation, rather than sedation, and advocate for extubation.

Repeatedly my attempts were shut down. I witnessed so much dehumanizing care that caused an amount of moral distress through which I could no longer work in the ICU. My own patients benefited from the removal of restraints, being allowed to be awake, move freely, and make their own end-of-life decisions while on a ventilator. I could not understand why others would not be willing to do the same. − Anonymous ICU nurse from Missouri

Nurses work incredibly hard for their patients, but they need to have as many calm, communicative, compliant, and functional patients as possible in order to ease their workload.

It is time for them to have real human connection and communication with the souls that they are diligently serving, and in order to do this, they must practice the ABCDEF Bundle, which enables optimal teamwork, collaboration, and support of nurses.

They also deserve to know they are giving their patients the best chance to survive and thrive and have the reward of watching patients succeed and walk out of the ICU doors [9].

When we started the ICU Liberation Bundle in our ICU one of the nurses was so excited to help his intubated patient have a ‘normal’ bowel movement in the commode instead of a loose stool in a bed pan. He was able to give his patient back some dignity and felt like while he did more work, it was more rewarding work. − Roni Kelsey, Washington

As we deal with this current nursing shortage, it’s important for us to make use of evidence-based sedation and mobility practices, which can lead to improved outcomes for both nurses and patients [11].

We must support nurses in their quest to master the ABCDEF Bundle so they can better handle their workload, workplace environment, bed flow, human connection, job satisfaction, and burnout [8].

The whole point of doing the ABCDEF Bundle is not to do the ABCDEF Bundle. It’s to facilitate better and more nurse-rewarding outcomes. ABCDEF is not the goal. The goal is what the ABCDEF elements bring. 

As someone who has done trauma, ER, MICU, COVID, and now does a lot of surgical heart work, the ABCDEF Bundle gets my patients to where I enjoy the care.

Getting my patients awake so they can get better gives me satisfaction and joy. Getting them awake to communicate with loved ones is hard work but it feels better than just turning every two hours for sedated, flaccid, and atrophying bodies. − James Fletcher, California

Do you want to turn your ICU into an Awake and Walking ICU? Contact us today to find out how we can guide you through the transformation.

References can be found here.

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How ICU Staffing Ratios Relate to the Awake and Walking ICU Approach

The Awake and Walking ICU approach is deeply rooted in science, pathophysiology, and logic.

Yet some of the best fruits of this method are humanity, compassion, dignity, and love.

We use this approach to humanize the ICU, and I believe that is a desire of most ICU clinicians.

But the reality is, no matter how much we want to treat our patients as the valued individuals they are, humanizing the ICU requires humans. Human hands. Human minds. Human time. Human touch.

A common response I get when sharing information on this subject is, “We do not have the staff to do this.”

On one level, I understand where these clinicians are coming from, as the implementation of these protocols is heavily dependent on having an adequate staffing level, and we’re currently in the middle of a staffing crisis.

But sadly, these kinds of statements reveal a deep misunderstanding of these processes.

The truth is the implementation of the ABCDEF Bundle should be seen as an investment rather than an expense.

These protocols provide a long list of benefits for patients, clinicians, and the hospitals where they practice, including better patient outcomes, improved working conditions, and cost savings that go far beyond what it would cost to hire enough staff to implement and sustain the ABCDEF Bundle.

I’ve been ecstatic to see that the adoption of these practices is becoming increasingly common, especially as more and more clinicians and hospital executives become aware of not just the clinical advantages of these protocols, but also The Financial Benefits of the ABCDEF Bundle.

But even though an increasing number of ICUs are trying to implement these practices, many are attempting to do so without adequate staff, as they’re failing to understand that adequate staffing is all part of the investment they’ll have to make in order to get the return.

This article offers insights into the benefits of this method and explores what the research says about ICU staffing ratios and the Awake and Walking ICU approach.

ICU Staffing Ratios and the Awake and Walking ICU Approach

Creating an Awake and Walking ICU requires full implementation of the ABCDEF bundle, and if you want to ensure it gets successfully implemented, you’ve got to have an adequately staffed ICU.

Having a shortage of clinicians can severely hinder your ability to provide the necessary attention, monitoring, and support that’s required to apply these practices.

That being said, if you want to fully realize the benefits of this method, it’s essential to address staffing challenges.

To give you a better idea of what I’m talking about, let’s explore several reasons why the Awake and Walking ICU approach cannot be properly applied without adequate staffing.

Continuous Monitoring and Assessment

The ABCDEF Bundle emphasizes regular assessment of the needs of patients, such as sedation level, delirium monitoring, and when patients are ready to be weaned off of sedation.

These assessments require the constant attention of clinicians, and inadequate staffing can lead to delays in assessments or incomplete evaluations, potentially causing complications to go unnoticed.

Early Mobilization and Rehabilitation

Early mobility and exercise are integral components of this process, but patients need assistance and supervision in order to engage in physical therapy and mobilization.

A lack of sufficient staff means patients may not receive the appropriate support for safe and effective rehabilitation, increasing the risk of complications and eroding their ability to properly implement these protocols.

Sedation Management

Proper sedation management is a key element of the ABCDEF Bundle. Nurses must be able to help decide whether or not sedation is needed, titrate sedation to the appropriate levels, and then be physically present to help patients safely emerge from sedation.

But when nurses have more than two patients, they are less able to assess and adjust their approach with each patient. They are unable to take the time needed to assess and treat pain and delirium, speak with patients, help them communicate with staff, educate family, and provide the care needed to help patients acclimate to the endotracheal tube and stay calm.

Nurses are left without support and unable to be at the bedside, and so sedation is often continued and sometimes increased.

When sedation management does not align with the ABCDEF Bundle, patients are oversedated, do not pass breathing trials, and remain on the ventilator for longer. This increases the risks and severity of delirium, which can double the nursing hours required for care, increase time in the ICU by 4.77 days, and increase costs by 39%.

At the end of the day, this kind of understaffing impacts sedation practices, which results in more ventilators, more occupied beds, more demand for clinicians, more work for ICU teams, more harm for patients, and more expenses for hospitals.

Ventilator Weaning and Extubation

Timely weaning from mechanical ventilation is essential to reduce complications associated with prolonged ventilation.

This process requires constant monitoring and timely adjustments. When patients had a need for sedation but now need to be weaned off, they are at high risk of emerging from sedation with delirium.

When this happens, patients can be confused, terrified, agitated, and difficult to keep safe from violence, line/tube removal, or falls.

The reality is, when an ICU is understaffed and a nurse is left alone with more than two patients and no team support, they are unable to provide the care needed, including things like communication, pain management, and early mobility.

This moment of panic and danger usually results in the resumption of sedation, and although the patient could likely be extubated that day, their delirium and resumed sedation will lead to more time on the ventilator.

This cycle often continues each day until patients are too weak to “fight” during their awakening trials, and this leaves patients vulnerable to higher risks of ventilator associated pneumonia, pressure injuries, delirium, central line and urinary tract infections, and ICU-acquired weakness.

These additional days or even weeks on the ventilator and in the ICU also increase the demand and workload for clinicians, while driving up expenses for hospitals.

But if you have the staff needed to help patients stay safe, calm, mobilize, communicate, and recover from delirium during awakening trials, it can help transform patient outcomes and drastically decrease staff workload and hospital costs.

Delirium Management

Management of delirium in the ICU requires careful monitoring, but when patients are deeply sedated it is impossible to assess them for delirium.

When sedation is turned off and patients have delirium, patients may need someone to sit at the bedside and continually re-orient them and monitor them to keep their lines and tubes safe. When nurses are understaffed, they are unable to provide this level of care.

Even patients that are not intubated can end up being sedated in response to delirium, as busy clinicians feel patients are safer when they are unable to move while they are in another room with another patient.

Patient care technicians can provide incredible return on investment when they help patients stay safe and free from sedation by providing human touch and attention.

At the same time, the increased time in the hospital, risk of readmission, and legal liabilities from improper delirium management can be a significant risk for hospital finances.

With that in mind, adequate staffing can help to protect patients, clinicians, and hospitals.

Family Engagement

The Awake and Walking ICU approach focuses heavily on family engagement and empowerment, as families play a vital role in the patient’s care and decision-making.

But without sufficient staff, the time and attention required to effectively communicate with and support families may be limited, potentially leading to misunderstandings, anxiety, dissatisfaction, and an erosion of trust in clinicians and the healthcare system in general.

Quality of Care and Burnout

In an understaffed ICU, clinicians are more likely to experience burnout, which can have a significant impact on the quality of care they’re able to provide.

Overworked staff may struggle to consistently adhere to the protocols outlined in the ABCDEF Bundle, which can jeopardize patient safety and outcomes.

Failing to practice the ABCDEF Bundle deprives hard-working clinicians of the satisfaction and fulfillment of seeing their patients succeed and walk out the ICU doors as a result of their labors.

And having to witness consistently poor patient outcomes, despite their diligent efforts, can drastically exacerbate burnout for clinicians.

Patient Safety

Inadequate staffing levels can compromise patient safety in various ways, such as an increased risk of medication errors, falls during mobilization, and inadequate infection control measures.

All of these factors can have a significant impact on the well-being of critically ill patients, while exposing clinicians and hospitals to potentially devastating legal liabilities.

My Take on ICU Staffing Ratios

When I worked as a nurse in an Awake and Walking ICU, two patients to one nurse was standard.

In that 16-bed ICU, we had a certified nursing assistant (CNA) on the unit, and physical and occupational therapists prioritized the ICU, but also worked on the medical floors.

Physical therapists worked with us to do two mobility sessions with our patients during the day and I utilized respiratory therapists (RTs), CNAs, and family to mobilize my patients on night shifts.

To many, these may seem like “normal” staffing ratios. To others, this may seem like a far-off dream, as some ICUs in this country are regularly giving ICU nurses three patients and charge nurses are taking their own patient loads.

At any rate, ICU staffing ratios should never exceed one nurse for two patients. It is well-known that higher ratios impair the ability to do adequate monitoring or properly administer medications, for instance.

And if nurses are trying to handle more than that, it is impossible to create an Awake and Walking ICU.

What is often left out of the discussion on ICU staffing ratios is the effect they can have on sedation and mobility practices, and therefore patient outcomes and healthcare costs.

The Awake and Walking ICU approach to sedation and mobility requires patients to remain awake, calm, communicative, and mobile. This is impossible without enough expert nurses, attentive CNAs, available RTs, accessible physical and occupational therapists, and involved providers at the bedside.

This approach requires human hands to hold patients’ hands, move their lines, gather equipment, push the ventilator, and help patients walk, and when patients are confused or agitated, it requires time and attention to address their needs, instead of just sedating them.

The entire team needs to have the bandwidth to see beyond the tasks, procedures, and medications and focus on the bigger picture for each patient, and all of this requires adequate staffing ratios.

Many have assumed that an Awake and Walking ICU requires a 1:1 ratio. Undoubtedly, such ratios would provide the most optimal care and outcomes for patients, and would help to mitigate burnout while improving the work environment, and staff retention, which by itself would likely lessen healthcare costs.

Nonetheless, in the current situation, such ratios are not attainable. However, we cannot afford to continue using standard sedation and mobility practices, especially during the current staffing crisis.

Why You Can’t Afford to Not Practice the ABCDEF Bundle

As I’ve already mentioned, the ABCDEF Bundle offers significant benefits for both patients and clinicians, along with the hospitals where they practice.

There is vast evidence to support this, but many stakeholders still aren’t aware of this.

If you’re still on the fence about hiring the staff that’s required to implement this approach, it’s important that you understand its advantages, particularly when it comes to the financial benefits, as well as the consequences of not practicing it.

For one thing, increasing the number of patients to each clinician is known to increase the risks and harm to patients, all of which drive up costs.

An observational study showed that when nurses have more than 2.5 patients, their risk of death increases by 3.5 times.

In another study, increasing the ratios by one RN per patient decreased the risk of hospital-acquired pneumonia by seven times, unplanned extubations by nearly five times, respiratory failure by four times, cardiac arrest by over seven times, and the length of stay decreased by 24%.

We also know, based on at least one review of nursing and medical literature, that the greater the nursing workload, the more falls, central-line associated blood infections, staff turnover, and staff no-shows occur.

As was shown in another systematic review, this is all part of the reason why better ICU staffing ratios actually decrease patient care costs.

At the same time, as this systematic review and meta-analysis shows, we know that sedation drastically increases time on the ventilator and time spent in the ICU.

Even in a study comparing interrupted sedation to no sedation, the no-sedation group spent over four days less on the ventilator.

We see in one study, which came to the same conclusions as many others, that early mobility (even at a lower dose than in an Awake and Walking ICU) decreases ICU length of stay by 20% and increases discharges home without services by 22.3%.

Moreover, we know that delirium doubles the nursing hours required for care, increases workplace violence, increases line and tube removals, increases falls, and ultimately increases time in the ICU and hospital by 4.77 and 6.67 days, respectively.

We also know that the ABCDEF Bundle, even when used at suboptimal doses, decreases delirium by 25-50%, and sedation alone increases the risk of delirium by 8.5 times.

What’s more, ICU-acquired weakness can prolong time on the ventilator by 20 days in sepsis patients.

One study found that an ICU team that increased its CVICU-dedicated physical and occupational therapists from two to four clinicians experienced a 3.6-day decrease in ICU length of stay!

Furthermore, ICU-acquired weakness and delirium are extremely laborious and taxing for our ICU teams.

Delirious patients are much more difficult and dangerous to deal with, and creating weak and dependent patients increases the demand for turning them every two hours, pressure injury care, more staff needed for mobility, more wait times for care facility discharges, and more time on the ventilator.

That being said, delirium increases healthcare costs by 39% and ICU-acquired weakness increases costs by 30.5%.

Fortunately, the Awake and Walking ICU approach protects patients and staff from delirium and ICU-acquired weakness.

This approach also minimizes complications, which decreases the time patients spend in the ICU and the demands that are placed on ICU teams.

And by allowing most patients to be awake shortly after intubation, the ABCDEF Bundle makes it more likely that patients will be oriented, calm, communicative, and therefore cognitively and physically able to participate in their care.

They are usually able to help mobilize themselves and this can also help decrease the staff and time required for each mobility session.

In addition, they’re also more likely to be able to successfully extubate and walk out of the hospital doors themselves, minimizing the care required for mechanical ventilation.

As a result, ICU bed flow becomes less dependent on bed openings in care facilities, and ICU staff are less burdened by the stress of delirium, ICU-acquired weakness, and having to do an incredible amount of work for poor outcomes.

At the same time, clinicians in an Awake and Walking ICU learn to utilize and optimize each other’s expertise for an efficient process of care that then minimizes the care patients require.

And all of this leads to at least a 30% decrease in healthcare costs.

All things considered, we cannot afford to continue practices that increase time in the ICU, nursing demands, risk to staff, burnout, and poor staff retention.

The Awake and Walking ICU approach guides teams to work smarter, not harder, and it represents one of the biggest possible returns on investment in the hospital system.

So, during this financial and staffing crisis, instead of asking, “Can we afford to hire the staff that’s required to implement these practices?” maybe it’s time to look at the bigger picture and ask, “Can we afford to not practice the ABCDEF Bundle?”

Do you want to turn your ICU into an Awake and Walking ICU? We can guide you through the entire transformation, and we look forward to discussing your team’s needs. Please contact us here.

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The Financial Benefits of the ABCDEF Bundle

The ABCDEF Bundle is easily the best tool we have to improve patient care and outcomes in the ICU.

If you know anything about these evidence-based practices, you’re probably well aware that they can decrease length of stay and readmissions, and reduce patients’ chances of dying, while making it more likely that they’ll return to their normal quality of life after leaving the hospital.

These few benefits only scratch the surface of the importance of these practices, but even still, the majority of ICUs have not implemented them.

So, why is it that so many hospitals have failed to apply these life-saving protocols?

As I’ve learned during my time as a clinician and a consultant, there are many reasons for this, but I think one of the main ones is a lack of understanding, particularly when it comes to the financial benefits of the ABCDEF Bundle.

I’m happy to say that today, many ICU clinicians have at least some awareness of the benefits that these practices provide for their patients, but most financial stakeholders are unaware of the financial benefits of applying the ABCDEF Bundle in the ICU.

This represents a big part of the reason why we’re still seeing so much resistance to the use of these practices, as the perception is that even though they can drastically improve patient care and outcomes, their implementation will be incredibly costly.

But adopting the ABCDEF Bundle shouldn’t be seen as an expense, and the truth is, applying these evidence-based practices can help you to save much more money than it would cost to actually implement them.

So, if you’re looking to invest in the wellbeing of your patients while boosting your ICU’s bottom line at the same time, then I hope you keep reading.

Because in this article, I’m going to explain what the ABCDEF Bundle is, explore the financial consequences of not implementing these practices, and discuss the financial benefits that they can provide for your ICU.

What Is the ABCDEF Bundle?

By this point, I hope you’re already familiar with the ABCDEF Bundle.

But for those of you who aren’t quite sure what it is, or need a bit of a refresher on these evidence-based practices, I felt it was important to explain.

The ABCDEF Bundle, also known as the ICU Liberation Bundle, is a set of evidence-based practices used in critical care medicine to improve the care and outcomes of critically ill patients, particularly those who are mechanically ventilated.

Each letter in the bundle represents a specific element of care aimed at reducing the harmful effects of prolonged sedation, immobility, and extensive intensive care unit stays, such as delirium, ICU-acquired weakness, and ICU-acquired PTSD. The ABCDEF Bundle includes the following components:

A) Assess, Prevent, and Manage Pain

This involves assessing pain using patient reported pain scales when patients are able to report pain, or utilizing observational pain tools to assess and monitor pain levels.

Pain is then adequately treated using the PADIS guidelines to use opioid and non-opioid medications as well as non-pharmacological interventions to manage pain.

B) Both Spontaneous Awakening and Breathing Trials

Daily awakening and breathing trials involve the routine cessation of sedation and ventilator support to assess for continued need for sedation and/or mechanical ventilation.

Awakening trials should be done as soon as there is no longer an indication for sedation and at least daily when an indicator for sedation has been present.

C) Choice of Analgesia and Sedation

The ABCDEF Bundle encourages the use of pain management techniques and sedation strategies that minimize the use of opioids and sedative medications, which can contribute to delirium and prolonged mechanical ventilation.

This step should guide clinicians to ask after each intubation, each day, and for each patient, “Is there an indication for sedation? And do the potential benefits outweigh the significant risks of sedation?”

D) Delirium: Assess, Prevent, and Manage

This component focuses on assessing and addressing delirium in ICU patients.

Delirium is a state of acute confusion and altered mental status that can be common in critically ill individuals, particularly those who’ve been sedated for long periods of time.

Strategies for preventing and managing delirium include using validated assessment tools, avoiding deliriogenic medications such as sedatives, addressing underlying causes, and promoting a calm and structured environment.

E) Early Mobility and Exercise

This part of the bundle promotes early mobilization and physical therapy for critically ill patients.

Encouraging patients to move, even while they’re still on mechanical ventilation or have limited mobility, can help prevent muscle weakness and improve overall functional outcomes.

F) Family Engagement and Empowerment

Recognizing the importance of involving the patient’s family in their care and decision-making process, this component encourages communication with family members, providing them with information and support, and involving them in the care plan whenever it’s appropriate.

Families are also powerful tools to prevent and treat delirium and are therefore encouraged to be engaged with the patient as much as possible, without visiting hour restrictions.

Implementing these practices is associated with better patient outcomes, shorter ICU stays, reduced delirium and weakness, and improved long-term quality of life for survivors of critical illness, among many other benefits.

As a result, an increasing number of clinicians in critical care settings are beginning to adopt the practices described in the ABCDEF Bundle as a framework to guide their care practices and improve the overall patient experience.

That being said, the benefits of these evidence-based practices extend far beyond patient care and outcomes, and can actually confer significant financial benefits to the institutions that implement them.

What Are the Financial Consequences of Not Applying the ABCDEF Bundle?

Unfortunately, there are still far too many clinicians out there who believe the myriad myths and misconceptions about the ABCDEF Bundle, like the idea that it’s an unaffordable expense.

But in reality, ICUs that choose not to implement these evidence-based practices can end up suffering some serious financial consequences.

So, before we look at the financial benefits of the ABCDEF Bundle, let’s take a look at some of the problems that can be caused by choosing not to adopt these practices. This includes things like:

Increased time on the ventilator

Increased delirium

More ICU and hospital readmissions

Patients needing to be discharged to care facilities for weeks to months of rehabilitation

More hospital-acquired infections, such as hospital and ventilator-associated pneumonia, central line-associated bloodstream infections, and catheter-associated urinary tract infections

More hospital-acquired pressure injuries and falls

Increased injuries to staff

Increased workload for staff

Heavier psychological burden on staff, leading to burnout

What’s more, evidence continues to mount, which shows that:

Sedation increases the risk of delirium by over eight times.

Immobility and bed rest can significantly increase the risk of delirium.

Delirium increases healthcare costs by 39%.

Delirium increases time in the hospital by 4.77 more ICU days and 6.67 more hospital days, on average.

Delirium can double the nursing hours required for care.

Delirium significantly contributes to the psychological burden on nurses.

Failure to mobilize patients leads to ICU-acquired weakness.

ICU-acquired weakness increases healthcare costs by 30.5%.

ICU-acquired weakness leads to more re-intubations, tracheostomies, and prolonged time on the ventilator.

For sepsis patients, ICU-acquired weakness can increase time on the ventilator by 20 days.

These kinds of issues can have an extremely detrimental effect on patient outcomes, but they can also significantly increase the healthcare costs incurred by your ICU.

That being said, now that you know the consequences of failing to implement the ABCDEF Bundle, let’s review the financial benefits that these evidence-based practices can provide.

And if you’d like to learn more about the cost of not implementing these protocols, you should check out Episode 95 of my Walking Home From The ICU podcast.

What Are the Financial Benefits of the ABCDEF Bundle?

Once clinicians stop viewing the implementation of the ABCDEF Bundle as an unwanted expense and start seeing it as the investment it truly is, then more ICUs will begin to adopt these practices, and that’s a win-win-win for patients, staff, and hospital systems.

So, with that in mind, let’s take a look at how these evidence-based practices, such as early mobility and avoiding sedation, can boost your hospital’s bottom line, while also offering better care and outcomes for your patients.

Avoiding sedation has been proven to:

Prevent/minimize delirium

Decrease time on the ventilator

Reduce the length of ICU and hospital stays

Early mobility has been proven to:

Prevent/treat ICU-acquired weakness and diaphragm dysfunction

Minimize time on the ventilator

Reduce the length of ICU and hospital stays

Increase the number of patients discharged home

Decrease hospital-acquired infections by 60% with a 300% increase in mobility

Decrease ventilator-associated pneumonia by 40% for each day mobility level is increased

Increase discharges home

Investing in adequate staffing has also been proven to directly decrease healthcare costs. A study from Brazil found it was cheaper to have physiotherapists in the ICU 24 hours a day rather than 12 hours a day.

In another study, an ICU increased its physical and occupational therapy staffing from two therapists to four, which increased the dose of early mobility provided to patients and decreased ICU length of stay by 3.6 days.

In addition, minimizing sedation alone has been proven to reduce healthcare costs. A studyfound that the PAD initiative in one hospital led to a 46% decrease in sedation and analgesia use. This resulted in saving $183,216 in drug costs and $1.2 million in savings for direct hospital costs.

The ABCDEF Bundle has also been shown to:

Decrease healthcare costs by up to 30%

Decrease ICU readmissions by 46%

Reduce the incidence of delirium by 50%

Increase patients’ chances of being discharged home by 36%

These incredible benefits were found, on average, even with low levels of compliance. It’s also been discovered that outcomes are dose-dependent, which means that the more teams adhere to an Awake and Walking ICU approach, the better outcomes will be.

A study from Johns Hopkins that evaluated the potential cost savings of implementing the practices found in the ABCDEF Bundle found that an investment of the 2023 equivalent of $114,455.85 resulted in net savings of $4,916,213.94.

In addition, a study from the Journal of Trauma Nursing found that in one ICU, the implementation of an early mobility program resulted in more than $8,000 in cost savings per patient.

As you can see, investing in these practices can have a major impact on a hospital’s bottom line, and many of these benefits can be achieved, even with low levels of compliance. However, the better the compliance, the better the outcomes, and chances are, greater compliance will result in even greater cost savings.

Unfortunately, the failure to support ICU teams with adequate staffing, education, and training is leading to a severe financial crisis within our hospitals and healthcare systems.

All things considered, now is the time for hospital systems to recognize the financial benefits of the ABCDEF Bundle. We must stop viewing its implementation as an “extra expense” and realize that it’s actually an investment in the health of patients, the well-being of clinicians, and the financial stability of the healthcare system.

Do you want to implement the ABCDEF Bundle in your ICU? We can guide you through the entire transformation, and we look forward to discussing your team’s needs. Please contact ushere.

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Patients and Their Families Have the Right to Know the Risks of Sedation

Patient autonomy is a pillar of clinical ethics, and it’s vital to the integrity of any clinical practice.

Observance of this principle works to uphold patients’ rights, fosters trust and collaboration, respects diversity, and empowers individuals to actively participate in decision-making regarding their healthcare.

In our efforts to protect patient autonomy, one of the best tools we have is informed consent. This is something of which every clinician is acutely aware, not least in the ICU.

Before we begin any surgical procedure, for instance, surgeons and anesthesiologists ensure informed consent is obtained from the patient and/or their family. Any risk, no matter how unlikely, is disclosed so patients and families are able to make their best decision and clinicians are protected from legal liabilities.

Even routine procedures like inserting a central venous catheter, arterial line, or endotracheal tube, or performing diagnostic tests, like a CT scan, require us to obtain informed consent.

In the ICU, the process of obtaining informed consent is ubiquitous, and no experienced clinician would question the legitimacy of this process.

When it comes to sedation, however, there is no standardized requirement for informed consent. Culturally, it is not considered to be necessary to tell patients and/or families of the life-threatening and life-altering risks of continuous sedation.

But the truth is, the risks of prolonged sedation can be just as serious as anything else we do in the ICU, and the need to obtain informed consent is just as important for sedation as it would be for surgery.

With that in mind, patients and their families need to be properly informed of the risks of sedation, and the risks of immobility, delirium, ICU-acquired weakness, and everything else that’s associated with being sedated.

Neglecting to obtain this informed consent is putting patients at risk, exposing ICU clinicians and the hospitals where they work to potentially serious legal consequences, and eroding hard-won trust in our healthcare systems.

In this article, we’ll be exploring the ethical conflict and legal liabilities of failing to inform patients and/or families of the risks of sedation and why in many cases, it’s so important to offer the option of avoiding sedation.

Why Aren’t Clinicians Obtaining Informed Consent for Sedation?

Truth be told, despite all the evidence to the contrary, many clinicians don’t consider sedation to be a dangerous intervention.

In the ‘90s, sedation became synonymous with intubation, and back then, we hadn’t done the research to show the risks of sedation, so no one was the wiser.

Several decades later, sedating every intubated patient has become standard practice in most ICUs.

This “malignant normality” leads us to believe that sedation for every intubated patient is an unavoidable, routine, and even benign practice, and this prevents clinicians from seeing the reality of sedation and immobility.

Believe it or not, most clinicians are actually unaware of the risks patients incur the moment they start continuous sedation drips.

This perspective prevents clinicians from critically thinking and performing a risk versus benefit analysis prior to starting sedation.

And when clinicians believe that sedating every intubated patient is a non-negotiable necessity for everyone, then there is an innate assumption that there is no need to obtain informed consent.

To be clear, clinicians do not intend to harm patients or have unethical practices. But when they don’t know the risks at hand, they are unable to be honest and transparent with families and/or patients.

Nonetheless, the risks of sedation are very real, and it should be standard practice to make patients and/or their families aware of this and obtain true informed consent before sedation is started.

What Are the Risks of Sedation?

For many years now, ICU clinicians have been operating on the assumption that sedation is “sleep.”

They believe that keeping intubated patients heavily sedated is harmless and the most humane thing we can do for them.

Unfortunately, nothing could be further from the truth, and this is backed up by 20 years’ worth of research, which has shown that it’s actually the opposite that’s true.

But informing clinicians of the risks of sedation, and all the side effects that go along with it, is the first step in exposing these myths for what they are and putting an end to these assumptions once and for all.

With that in mind, below I’ve listed some of the risks of sedation, so you can have a better idea of the harm it can actually cause.

Sedation increases patients’ chances of:

Dying in the ICU

Dying after leaving the ICU

Delirium

ICU-acquired weakness

Infection

Pressure sores

Blood clots

Having to spend more time on the ventilator

Requiring more time in the hospital

Tracheostomy

Being discharged to a rehabilitation center or nursing home

Post-ICU PTSD

Post-ICU dementia (cognitive dysfunction)

Long-term physical disabilities

Depression

Being readmitted to the hospital or ICU

Post-intensive care syndrome

Sedation decreases patients’ chances of:

Being able to go home after being discharged from the hospital

Being able to walk when being transferred from the ICU

Having the ability to return to work

Enjoying optimal quality of life

In any case, deep sedation is an automatic predictor of mortality, and families have a right to know.

That being said, before starting sedation, no matter the circumstances, it is our duty as clinicians to obtain informed consent.

If you’d like to learn more about patient autonomy, informed consent, and the risks of sedation and immobility, you should check out Episode 62 of my Walking Home From The ICU podcast.

What Are the Benefits of Avoiding Sedation?

In the ICU, there are some situations where sedation is absolutely necessary, including things like intracranial hypertension, seizures, open abdomen surgeries, inability to oxygenate with movement, and even some drug toxicities or severe alcohol withdrawal, for example.

Fortunately, in many circumstances that require mechanical ventilation, avoiding sedation is in the best interests of everyone involved.

Nonetheless, the incredible contrast in outcomes between having patients awake and mobile during mechanical ventilation versus having them sedated and immobilized is grossly underappreciated.

And the reason for this is that most ICU clinicians have never had the opportunity to experience the success that tends to go along with having patients walking while intubated.

Yet when the benefits of avoiding sedation are listed, it becomes clear why informed consent is so important when it comes to this practice, and why, whenever possible, families and patients should have the option to avoid the risks of sedation.

Avoiding sedation has been shown to decrease:

Death

Ventilator and hospital-associated pneumonia

Central line and catheter infections

Pressure injuries

Falls

Delirium

Aspiration pneumonia

Constipation/ileus

Intubation

Re-intubation

Tracheostomy and PEG tube placements

Discharges to care facilities

Hospital and ICU readmissions

Diaphragm dysfunction

ICU-acquired weakness

Long-term cognitive impairments

Avoiding sedation has been shown to increase/improve:

Successful extubation

Discharges from ICU

Discharges home

Chances of survival

Functional independence after discharge

Quality of life

Lung aeration

Secretion clearance

Truth be told, the risks of sedation and immobility are far higher than many of the risks of surgery that are explained when obtaining informed consent for those procedures.

With that in mind, families and patients have the right to be aware of the damage that can be done by sedation and the potential impact it can have on short and long-term outcomes.

Moreover, the process of obtaining informed consent for sedation empowers patients and families to actively engage in their healthcare decisions. This creates a patient-centric environment that enhances trust, communication, and the overall quality of care, and strengthens the patient-provider relationship.

At the same time, clinicians can be safeguarded from legal and ethical dilemmas when informed consent for continuous sedation is honest and transparent.

And as clinicians who want nothing more than to save and preserve lives, our patients and their families should expect nothing less.

Do you want to implement evidence-based sedation and mobility protocols in your ICU? We can guide you through the entire transformation, and we look forward to discussing your team’s needs. Please contact us here.

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ICU Rounding Culture: What Needs to Change and How We Can Help

One of the biggest barriers to improving ICU patient care is a lack of interdisciplinary collaboration, especially when it comes to ICU rounding.

In theory, rounding should give clinicians the opportunity to review and discuss each patient’s care, and then come together to ensure that care is a reflection of best practices and the patient’s wishes.

It should promote effective communication and collaboration, allowing clinicians to work collectively to make more comprehensive and well-informed decisions, while helping teams to identify risks, improve patient safety, prevent errors or inconsistencies, and promptly implement necessary interventions.

Moreover, it should also enhance continuity of care by ensuring every member of the ICU team is on the same page about how each patient is to be treated, allowing for a seamless transition between shifts, and reducing the incidence of misunderstandings or misinterpretations.

Ideally, ICU rounding should also empower patients and their families by involving them in the decision-making process, enhancing their understanding of the care being provided, and giving them the opportunity to ask questions and voice concerns.

This all helps to promote a more patient-centered approach, while building trust, and enhancing the experience, quality of care, and outcomes of patients in the ICU.

But unfortunately, when it comes to ICU rounding, this is not how things usually play out.

The sad reality is, like so many other aspects of ICU culture, rounding routines can be hard to redirect, and this can create dire consequences for clinicians, patients, and the ICUs where they’re treated.

So, if you’re looking to improve ICU patient care by reevaluating your rounding processes, then you should definitely keep reading.

Because in this article, I’m going to explain what needs to change when it comes to ICU rounding culture, and how I and my team can help you to implement those changes.

ICU Rounding Culture: What Needs to Change

Participating in ICU rounding practices is one of the most important aspects of our consulting.

Observing ICU teams during this process allows us to assess how familiar clinicians are with evidence-based practices like delirium management and early mobility in the ICU, and the level of collaboration between clinicians.

At the same time, this also gives us the opportunity to jump in when we feel it’s necessary to address knowledge gaps and opportunities for application of the ABCDEF Bundle.

This allows us to ensure clinicians are following evidence-based practices, and that they understand the importance of these protocols, and how to implement them.

But unfortunately, we continue to find that, in general, the prevailing ICU culture has not normalized a rounding process that instinctively involves the ABCDEF Bundle.

With that in mind, below I’ve detailed several things that need to change when it comes to ICU rounding culture, so you can identify gaps and learn about tools that can help guide your team’s progress.

Not Taking Enough Time

When it comes to ICU rounding, a common issue I’ve seen is that some teams do not allow themselves enough time to conduct thorough rounds.

On the other hand, I’ve sat in on much more comprehensive rounding processes where they make a point of spending a significant amount of time on each patient.

These kinds of ICUs tend to be more on the academic side of things, where medical students or residents present, and attending doctors take time to teach and discuss things at length, often spending several hours completing their rounds.

But a lot of ICU teams are just trying to get through their patients as quickly as they can. Shockingly, sometimes they spend no more than 30 minutes on the entire process for 20 or more patients.

This kind of assembly line approach is not good for patients, as it does not provide enough time to discuss the many concerns related to critical illness, consider the humanity of each patient, or take a comprehensive look at each patient’s care.

Moreover, this also makes it pretty easy to overlook life-threatening issues, along with opportunities to educate and develop your team.

Ideally, the process should include all the key disciplines of your ICU team, including doctors, nurses, pharmacists, physical therapists and/or occupational therapists, dietitians, social workers, family members, and anyone else who is involved in the care of your patients.

The presenter should walk the team through all of the details related to each patient, including their name, age, why they were admitted to the hospital, the course of events that brought them to this point, their current condition, and what can be done to improve their care.

This requires careful consideration of several different aspects, including things that many ICU teams tend to overlook, like whether the patient is suffering from delirium, along with their CAM and RASS scores, level of sedation, level of mobility, and any barriers to mobility that they might be experiencing.

Then, once all of this has been discussed, the team can work together to determine if anything can be done to improve the patient’s care and implement any necessary interventions.

Lack of Collaboration

Lack of collaboration between clinicians is one of the biggest problems with ICU rounding culture.

It’s easy to skim through presentations quickly and try to get the whole thing over with as soon as possible. But it’s much more beneficial to build an environment that allows clinicians of each discipline to have a fair opportunity to provide suggestions and offer their expertise.

That being said, multidisciplinary rounds can actually be a lot different from interdisciplinaryrounds, which allow for true collaboration.

Interdisciplinary rounds happen when collaboration is warmly welcomed and proposals from colleagues are sincerely discussed, valued, and taken seriously.

But unfortunately, this is not how things tend to go when it comes to ICU rounding.

More likely, what will happen is something like this: A progressive physical therapist will be brave enough to suggest mobilizing a patient, but members of the ICU team, who don’t understand the ABCDEF Bundle, will respond by saying something like, “They’re still intubated, so we can’t,” or “They’re still sedated and they were too agitated during the last SAT this morning.”

But a team that truly understands the ABCDEF Bundle will use its rounds as an opportunity to bring each discipline together to develop plans on how to keep each patient as awake, mobile, and free of delirium and ICU-acquired weakness as possible.

For example, if a nurse reports that a patient has been sedated, a pharmacist may ask, “Is there an indication for sedation?”

And if the nurse responds by saying, “When we tried to turn it off, the patient became agitated and we turned it back on,” this provides an opportunity for a physician to ask, “Does the patient have delirium? And how can we turn the sedation off?”

Then, when a physical therapist says, “Let’s get the family to the bedside, and I would love to help you turn the sedation off and get the patient up,” the team will be much less likely to be hesitant about this suggestion, as they’ll understand the evidence, and how that approach can benefit them, the patient, and the ICU as a whole.

This method of ICU rounding encourages discussion and makes it more likely that clinicians will accept each colleague’s contribution to that conversation, and remain open to their suggestions, allowing everyone to be on the same page, and the load of patient care to be shared.

In addition, this allows ICU teams to make decisions regarding sedation, delirium, and mobility based on evidence, rather than culture and fear.

With that in mind, we make a point of always having a seasoned respiratory therapist and physical therapist with us while we’re on-site, because not only can they offer their expertise on these practices, and how to improve the rounding process, but this also helps us to reinforce the interdisciplinary approach and remind clinicians of the importance of all this.

We also make sure to train whomever is leading the rounds to create an environment that facilitates this kind of discussion, and provide them with a toolkit to ensure every member of the ICU team is prompted to follow this systematic approach to rounds.

At this point, it’s also important to mention that there is significant evidence to show the benefits of interdisciplinary collaboration during the rounding process.

For example, one study, which looked at the impact of allowing pharmacists to participate in multidisciplinary rounds, found a long list of potential benefits of this kind of collaborative approach.

The study found that allowing a pharmacist to perform daily sedation management for patients “resulted in fewer hours of patient exposure to continuous sedation, with an overall 46% reduction in continuous infusions of sedatives and reductions in both ICU and total hospital LOS, resulting in estimated savings of $1.2 million in direct hospital costs and $183,216 in drug costs.”

In addition, it found that allowing pharmacists to collaborate with ICU teams using the practices outlined in the ABCDEF Bundle offered “improvements in several outcomes, including mean ventilator days per patient, ICU LOS, and mortality.”

Not Digging Deep Enough

Another issue with ICU rounding culture is that teams may not dig deep enough to actually understand the barriers and needs of each patient.

This happens mainly due to a lack of understanding of evidence-based practices like delirium management and early mobility in the ICU, along with communication breakdown between clinicians, which is exacerbated by poor rounding practices, such as imposing strict time limitations.

For example, a nurse may report, “The patient was agitated and failed their SAT,” which means that sedation was resumed. But oftentimes, this is as far as the conversation will go, and the rest of the team will accept sedation as essential for that patient and something to address later on when it’s time to think about extubation.

However, a team that understands the ABCDEF Bundle will dive much deeper, and a colleague might ask questions like, “Why was the patient agitated? Were they in pain? How are they communicating? Do they have delirium? And was their family present during that awakening trial?”

Then, if the nurse confirms, “They’re CAM positive,” the physician can use that as an opportunity to help educate their team, and encourage them to make delirium, agitation, sedation, and mobility a priority.

At this point, a physician on this type of team might say something like, “This is acute brain failure. Sedation is likely causing, exacerbating, and prolonging their delirium. And for every one day of delirium, there is a 10 percent increased risk of death. This patient needs to have sedation turned off, and be mobilized, with their family present, while having their sleep prioritized.”

They can then ask the physical and/or occupational therapists to accompany the RN and RT to help with the awakening trial and promptly mobilize the patient with the goal of turning off the sedation.

This may also prompt the physician to join their team at the bedside during the awakening trial and help assess causes of agitation, such as pain, fear, or delirium.

These kinds of moments during rounds can be the difference between a patient being awake, mobile, communicative, and thriving, or continuing down the path of sedation, immobility, and the many complications that follow.

In any case, doctors need to have a deep understanding of delirium, ICU-acquired weakness, post-ICU syndrome, early mobility, sedation management, and the ABCDEF Bundle.

This expertise will help them orchestrate masterful collaboration for their teams by diving deep into the evidence, while considering the humanity and best interests of each patient.

Failing to Involve Family

I am also a strong proponent of involving patients’ family members in the rounding process.

But in my experience, ICU clinicians can have strong reservations about having families present during rounds. It seems to go against their culture, makes them feel uncomfortable, and even vulnerable to have families involved in the rounding process.

Much of this stems from a lack of understanding of the role and value of the family as key players in a patient’s survival in and outside of the ICU.

But the truth is, involving patients’ families in the rounding process offers many benefits, including:

Improved communication: Involving family members in ICU rounding facilitates open and transparent communication between healthcare providers and the patient’s loved ones, allowing for discussions about the patient’s condition, treatment plan, and progress. Their involvement promotes a better understanding of the situation, reducing anxiety, and helping to manage expectations.

Enhanced patient-centered care: Family members can provide valuable insights into the patient’s medical history, preferences, and values, and their presence during rounding ensures that the care plan aligns with the patient’s individual needs and wishes.

Emotional support: The ICU can be an overwhelming and stressful environment for both patients and their families, but allowing family members to participate in rounding offers emotional support and can alleviate anxiety and foster a sense of trust in the care being provided.

Shared decision-making: Inclusion of family members in rounding promotes shared decision-making, and involving the patient, their family, and the medical team can lead to more informed choices and increased satisfaction with the care provided.

Education and empowerment: ICU rounding provides an opportunity for family members to learn about the patient’s condition, prognosis, and ongoing care needs. It allows them to ask questions, seek clarification, and receive education about the patient’s treatment and post-ICU care.

Continuity of care: Involving family members in ICU rounding promotes continuity of care, as they become familiar with the patient’s care plan, which can be helpful when transitioning from the ICU to other healthcare settings or when managing care at home.

How We Can Help You Improve Your Rounding Process

When we work with your ICU team, we start by encouraging everyone to participate in our series of webinars, so they can better understand the why and how of the evidence-based practices in the ABCDEF Bundle.

Then, once we arrive on-site, the first step is to simply observe your current rounding process.

This allows us to see who is present during rounds, who is presenting, what kind of order or systematic approach is being used, which aspects of patients’ status and care are discussed, and how the team makes decisions.

After assessing all these aspects, we’ll work with your team to make your rounding process more succinct, thorough, and efficient, while ensuring delirium management, pain management, sedation, RASS, communication, family engagement, and early mobility in the ICU are included in the discussion.

The goal is to help your team have the understanding, tools, and team dynamics to apply the principles of the ABCDEF Bundle to your rounding process using a collaborative approach that optimizes each discipline’s expertise to ensure the best patient outcomes.

By the end of our training, each team member will understand why keeping patients awake and mobile is so important, along with how to go about doing this in the safest way.

What’s more, they will know how to discuss concerns and barriers during rounds and work together to develop a plan to overcome the unique challenges of each patient with the goal of giving patients the absolute best chance to walk out of the hospital doors, discharge home, and resume their normal lives.

Each team member will also learn the importance of a collaborative approach, and the value of each discipline’s contribution, while being equipped with a systematic method, based on the principles of the ABCDEF Bundle, which allows them to work with their team to provide the best possible care for each patient.

As part of that process, we also provide clinicians with a rounding tool, similar to the ICU rounding sheet shown below, which comes from the University of Colorado ICU and is actually based on the evidence-based practices we espouse.

This ICU rounding sheet will help to ensure that what we teach is not forgotten, and will go on to become a standardized part of the rounding process followed in your ICU.

Evidence shows that using this kind of tool can provide a multitude of benefits for any intensive care unit.

For example, one observational study found that implementing this kind of tool “can result in improvements in engagement of nursing staff and in overall communication.”

Another study looked at whether time allocation issues in the ICU could be solved by using a rounding tool, and it found that the use of these tools “potentially mitigates disproportionate time allocation and communication breakdowns during rounds,” with one tool “almost completely eliminating such effects.”

All things considered, ensuring that clinicians use this kind of ICU rounding sheet is integral to the improvement of the ICU rounding process, as it reinforces the importance of considering these aspects of patients’ care, and makes the implementation of this process more sustainable.

What’s more, once it becomes standard practice, and part of your ICU culture, clinicians will appreciate the benefits it provides to your team, your patients, and your ICU as a whole.

Do you want to improve the rounding process in your ICU? We are here to help! Let’s discuss your team’s needs. Contact us here.

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Unplanned Extubations: Dispelling the Fear and Understanding the Reality

When I think back to how I started my career as a nurse, it really does seem like a date with destiny.

I could have gotten a job at any ICU, but for whatever reason, I landed my first nursing gig at a high acuity medical-surgical intensive care unit in Salt Lake City, Utah, which just so happened to be an Awake and Walking ICU.

While I was interviewing for the job, the nurse manager asked me if I’d be willing to help patients mobilize during mechanical ventilation.

At the time, I had no idea what that meant, but I enthusiastically nodded my head and said, “Yes. Of course!”

Little did I know that this first nursing job would lead me down a path toward what I now feel is my life’s purpose, and it’s so inspiring to reminisce about how things have played out since that fateful day.

In any case, standard practice in this Awake and Walking ICU was to allow patients to wake up right after intubation and mobilize shortly thereafter, unless there was an indication that the patient needed to be comatose, or a contraindication to mobility.

Otherwise, intubated patients would always be up and cruising around.

At this point, you might be thinking that this doesn’t sound like a real high acuity ICU, or that these patients were all on the ventilator long-term, but nothing could be further from the truth.

Even during COVID, they insisted on allowing patients to mobilize while intubated, unless there was a need for them to be sedated, or they couldn’t oxygenate with movement.

And believe it or not, this ICU team went over two years without a single unplanned extubation.

But why is that?

Well, with any luck, you already know the answer, but if you’re not quite certain, or you just want to learn the truth about unplanned extubations, then you should definitely keep reading.

Unplanned Extubations and the ABCDEF Bundle

The main reason why this ICU was able to go so long without an unplanned extubation is that it adheres to the evidence-based practices in the ABCDEF Bundle.

This set of tools is meant to help clinicians customize and optimize patient care, particularly when it comes to early mobility, delirium prevention, and limiting sedation.

If you work in the intensive care unit, then I hope you’ve heard of it, but sadly, in spite of all its benefits, it’s not as well-known as it should be.

So, for the benefit of those of you who aren’t familiar with it, I’m going to explain how it works.

The ABCDEF Bundle works by prioritizing:

Family members being involved, which improves patients’ overall well-being and creates a need for them to be awake and communicative

Early active mobility, meaning patients will be able to get up and walk around while intubated, unless there’s a contraindication

Delirium prevention, assessment, and treatment, with the focus being put on prevention, which goes hand in hand with early mobility, as it’s known to prevent delirium

Considering our choice of sedation and analgesia, which not only encourages us to limit the use of benzodiazepines, but also to determine if sedation is even needed, and if it is, to always go with the safest sedative, at the lowest dose, and for the shortest duration

Both spontaneous breathing and awakening trials, which help clinicians to make a better assessment of exactly what a patient needs, while considering any delirium they’re experiencing and how best to treat it

Assessment, prevention, and treatment of pain, which is much easier when patients have not been sedated, and are actually able to communicate their needs, and what sort of pain they’re experiencing

These practices also encourage clinicians to avoid restarting sedation as soon as they witness a patient with delirium or agitation. This perspective helps them to understand that sedation is often responsible for patients being delirious or agitated, so it’s best not to sedate them unless it’s absolutely necessary.

The image below offers a perfect example of how beneficial these practices can be, as more than likely, the only reason that this man, who was a COVID patient, was able to remain awake long after being intubated, and still have enough energy to strum a guitar, is that he was treated using the practices outlined in the ABCDEF Bundle.

If you want to learn more about the ABCDEF Bundle, and the devastating effects of not adhering to these evidence-based practices, you can read my article on Susanne’s Story: How to Improve ICU Patient Outcomes with the ABCDEF Bundle.

And if you’d like to learn even more about unplanned extubations, you should check out Episode 112 of my Walking Home From The ICU podcast.

The Unnecessary Fear Surrounding Unplanned Extubations

Unfortunately, for many ICU clinicians, the idea of having patients awake and mobile while on the ventilator is actually quite scary.

What I often hear from clinicians who are skeptical of these practices is that they believe they’re unsafe because the patient could extubate themselves.

Now, unplanned extubations are a legitimate thing for clinicians to be concerned about, and they can have dire consequences, including everything from hypoxemia and hypotension to respiratory failure, aspiration pneumonia, or even death.

But when we look at the evidence, it’s actually very rare for an unplanned extubation to take place as a result of early mobility. One meta-analysis that included over 14,000 activity sessions showed a rate of adverse events, such as cardiac arrhythmias, hypoxia, hypotension, falls, and unplanned extubations, of just 0.6 percent.

And when we compare this to something as innocuous as bed baths, for instance, where unplanned extubations are one of the most common events, this is when things really get put into context, and we realize that the fear of unplanned extubations happening during mobilization is completely blown out of proportion.

Sure, unplanned extubations can happen while a patient is ambulating, and this can cause serious complications, but it’s no more likely to happen during early mobility than it is during many other routine practices in the ICU. In fact, it’s quite the contrary.

So, which one of these practices is more dangerous in the context of unplanned extubations? Bed baths or early mobility? I think the answer is obvious, but I’ll let you be the judge.

And when we look at the risk factors for unplanned extubations, this is when everything starts to make sense, and we realize that delirium is one of the main reasons why these unfortunate events occur.

In fact, several of the risk factors for unplanned extubations are directly related to patients experiencing delirium, and how they got into that state in the first place.

Some of these risk factors include patients’ restlessness and agitation, the use of Midazolam to decrease that agitation, the use of physical restraints, which has a correlation with delirium, and issues related to nursing staff, such as inexperience and inadequate staffing.

And when I think about the fact that I’ve personally witnessed thousands of patients who were awake and mobile on the ventilator, and these situations almost never resulted in an unplanned extubation, I realize how important it is for me to relate these risk factors to what I’ve experienced in the ICU.

Because in my experience, unplanned extubations have tended to occur when patients are restrained, and when they were restrained, it’s because they were delirious.

Aside from my own observations, this is also shown in the literature on unplanned extubations, especially when you look at newer studies on this topic.

For example, an Asian Nursing Research study from 2017 found delirium and agitation to be two of the biggest risk factors for unplanned extubations in critically ill patients, with delirium increasing unplanned extubations by 11.6 times, and agitation increasing them by nine times.

Still, even today, in spite of this kind of research being widely available, clinicians don’t seem to understand the seriousness of delirium, or the risk factors that can go along with it.

But the fact of the matter is delirium is a symptom of acute brain failure, and a life-threatening medical emergency.

That being said, there are many different reasons why delirium occurs, and despite the good intentions of clinicians, unfortunately, we often contribute to the development of delirium with many of the outmoded protocols that are still being practiced in ICUs to this day.

For instance, when sedating a patient, many clinicians believe that this is the most benevolent and humane thing they can do. The prevailing ICU culture has led them to believe that sedation is sleep, and that sedated patients are as calm and comfortable as they appear to be as they lie motionless in their beds.

But this just isn’t true. And if you look at the research, and listen to the agonizing stories of patients who’ve gone through the experience of being sedated for long periods of time, you’ll learn that sedation is not sleep, and it’s not sparing patients the stress and trauma of being in the intensive care unit.

On the contrary, it’s actually a form of sleep deprivation, and one that’s known to cause trauma, not mitigate its impact.

The truth is, the experience of being sedated can be incredibly traumatic for patients, many of whom experience horrible nightmares, or worse, for days and weeks on end as they remain sedated, and this is yet another reminder of why we should never sedate a patient unless it’s absolutely necessary.

I’ve documented the testimony of many patients who’ve experienced this for themselves, and if you’d like to hear some of their stories, you can skip to the 17-minute mark in the video below.

https://youtu.be/_LC527FV25c

The Costs of Delirium in the ICU

Regardless of all the well-intentioned, yet erroneous beliefs about sedation that still persist in ICU culture today, the fact is, sedation is known to cause delirium, and patients with delirium are:

Three times as likely to die within six months after discharge, and with each day of delirium, there is a 10 percent increase in their risk of death (Ely, 2004)

Likely to spend more time in the ICU, and more time hospitalized (Dziegielewski, 2021)

Prone to increased time on the ventilator (Arumugam, 2017)

At increased risk of line and tube removals (Tilouche, 2018)

More likely to die one year after discharge (Pisani, 2009)

Less likely to discharge from the ICU (Klouwenberg, 2014)

Two times as likely to die during admission (Salluh, 2015)

What’s more, failing to manage delirium can also create serious consequences for our healthcare system, as well as individual ICUs and the clinicians who work in them, including:

Increased risk of workplace violence from patients experiencing delirium (Jakobsson, 2020)

Higher healthcare system costs of up to $152 billion per year (Leslie, 2008)

Up to 39 percent higher intensive care unit costs (Milbrandt, 2004)

Increased workload for clinicians (Sieber, 2021)

So, as you can see, by following outdated practices, like deeply sedating all ICU patients, we’re not doing them any favors. We’re actually putting them at a much greater risk of suffering from delirium, and all the risk factors that go along with it, like unplanned extubations.

And as clinicians, we’re not doing ourselves, our industry, or our reputations any favors either.

Now, before I conclude, I’d like to summarize a story from Dr. Wes Ely, who is the creator of the ABCDEF Bundle.

This anecdote involves a 27-year-old wheelchair-bound patient who had returned to an ICU where Dr. Ely was visiting after having been there two years prior for bleeding in her lungs.

The reason she was in a wheelchair is that as a result of being sedated and immobile for so long in the ICU, she had suffered severe muscle loss in her legs and could no longer walk, even two years later.

Dr. Ely asked the clinicians who treated her why they kept her sedated and in bed for so long, and they said they were afraid she would self-extubate, to which another doctor asked, “But what if she never walks again?”

It’s stories like this that show just how important it is to avoid sedating ICU patients whenever possible, and how blown out of proportion our fears about unplanned extubations truly are.

With that in mind, I’ll conclude by saying that although unplanned extubations are a legitimate concern, we should not fear things like early mobility. What we should be afraid of are outdated practices like automatically sedating every patient who comes into the ICU, or keeping patients sedated for long periods of time.

Because sedation and immobility are the main modifiable causes of delirium in the ICU, and when it comes to unplanned extubations, delirium is one of the most well-known culprits.

But by doing whatever we can to prevent ICU delirium, we can keep patients safe from the risks of unplanned extubations.

Are you interested in implementing the ABCDEF Bundle in your ICU? We can walk you through the entire process, so please don’t hesitate to contact us.