“The coronavirus pandemic is like a delirium factory. If you had to design an experiment to make delirium as big of a problem as you could in an ICU, COVID is it.” Dr. Wes Ely, April 15, 2020 in an interview with CNN.
In the early days of caring for critically ill patients with acute respiratory distress syndrome, sepsis or multiple organ failure, we were grateful when they survived their illness. We used any interventions we could think of to increase the likelihood of survival. We didn’t really think about what came after patients’ intensive care unit (ICU) experience; we were just happy they survived. However, we came to find out that despite our best efforts, these patients had a high risk of developing delirium and postdischarge sequelae.
Here’s What We Know
Patients who develop delirium during their ICU stay have a high risk of developing post-intensive care syndrome (PICS). This syndrome is a combination of cognitive, psychological and physical signs and symptoms that may persist for months or years after discharge from the ICU. Patients who develop PICS have a decreased quality of life and may not be able to return to employment or their previous level of activity and cognitive acuity. Family members are also likely to develop a similar syndrome related to the patient’s experience.
Across the country, ICU teams have implemented processes to prevent or limit patients’ risk of developing delirium and PICS. These processes are based on the ABCDEF bundle, the framework for the Society of Critical Care Medicine’s ICU Liberation initiative and the usual standard of care for ICU patients at risk for developing delirium and PICS.
PICS and COVID-19
Some hospitals are still able to function at the conventional level of care and should continue to implement the full ABCDEF bundle. However, many facilities and patient care units may be functioning at contingency capacity, which means the standard of care may need to be modified.
Some hospitals and patient care units are functioning in crisis mode. Under these conditions, the use of the ABCDEF bundle to prevent delirium will need to be adapted to available resources, which may lead to a large number of survivors at high risk for PICS. Stories of patients and families who are experiencing the effects of this syndrome during the COVID-19 pandemic are already emerging in the media.
Here’s How You Can Use the ABCDEF Bundle:
- Assess and Manage Pain. If pain is managed successfully, the patient may require less sedation. Medication shortages may mean you are using different medications than usual to manage patients’ pain. Continue to assess patients for pain using validated tools, and consider using both pharmacological and nonpharmacological (music, backrubs, skin care) interventions.
- Both Spontaneous Awakening Trials (SATs) and Spontaneous Breathing Trials (SBTs). If a patient is unstable or still being proned, healthcare providers may discuss holding off SATs and SBTs. Continue to discuss the timing of these trials with the team, and start the SAT as soon as possible to evaluate the patient’s neurological status and the ability to reduce sedation. Continue to reorient patients to day, time and treatment plan. Identify language barriers and translation needs for both patients and their family members.
- Choice of Analgesia and Sedation. Be sure to administer analgesics before sedatives. If your facility is experiencing medication shortages, you may be using more benzodiazepines; remember, benzodiazepines have a different effect than propofol or dexmedetomidine. Administer the least amount of sedation possible under these conditions, using tools such as the Richmond Agitation-Sedation Scale (RASS) and the Sedation-Agitation Scale to monitor patient response. Evaluate the interaction of the medications you are using to manage pain and sedation.
- Delirium: Assess, Prevent and Manage. Use validated tools for assessment of delirium. Decrease unnecessary noise, try to manage day and night orientation, and check with family members about visual or hearing needs. Be sure to talk with your patients about familiar things, such as their family, pets or the weather, and about the care you will be providing. Allow time for patients to have uninterrupted sleep.
- Early Mobility and Exercise. Some patients with COVID-19 have been proned up to 36 hours at a time. You may not be able to get your patients out of bed or perform range-of-motion exercises. The best you may be able to do for your patients is to limit potential injury from improper positioning and skin breakdown. Implement early mobility assessment as soon as appropriate.
- Family Communication and Empowerment. Family visitation is likely restricted or eliminated to protect family members from COVID-19. Use your regular communication strategies such as designating a family member as the contact, deciding on a routine time and method for communication, and identifying any language barriers and translation needs. Include social workers, chaplains and other team members to help determine the best methods to communicate with family. You may have access to cellphones and iPads for direct communication. If you are using visual communication, be sure to explain to family members what they will see in the patient’s room, such as equipment or the other staff members.
- The article “2018 Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU” is published in Critical Care Medicine.
- An article in the American Journal of Critical Care discusses the “Effect of ABCDE Bundle Implementation on Prevalence of Delirium in Intensive Care Unit Patients.”
- An article in Critical Care Nurse examines “Common Challenges to Effective ABCDEF Bundle Implementation: The ICU Liberation Campaign Experience.”
- The webinar “Guideline Update: Bundle up for Pain, Agitation and Delirium” explains how to use the 2018 PADIS guidelines to achieve best patient outcomes.
We know following the ABCDEF bundle is best for our patients — so how are you creatively trying to prevent PICS with these patients?