As critical care practices continue to develop, there is an increasing awareness and understanding that some aspects of common care increase complications for patients during and after their hospitalization. This awareness has led to a particularly interesting exploration of the interrelationship among over-sedation, unrecognized delirium, immobility, and lack of sleep. These reinforcing complications can lead to long-term harm and are strong predictors of increased length of stay, morbidity, mortality, long-term cognitive impairment, and cost of care.
The diagram below shows these interrelationships. For example, overuse of sedation decreases the likelihood of useful mobility for a patient, increases delirium risk, and decreases restorative sleep. Similarly, delirium increases likelihood that patient will receive oversedation, will not be considered a candidate for mobility, and will have affected sleep. Alternatively, mobilizing critically ill patients can make apparent the decreased need for sedation, can improve sleep, and can help delirium clear.
Source: T. Clemmer, 2011
Key Changes for Improvement
- Use the "ABCDE" mnemonic to coordinate daily plan of care:
- A = Awakening
- B = Breathing
- C = Coordination and choice of sedation
- D = Delirium monitoring and management
- E = Early mobility/exercise
- Use sedation protocol designed to reduce sedation
- Use mobility protocol to progress patient mobility daily
- Monitor for delirium throughout day and address when identified
- Establish high-functioning interdisciplinary rounds to promote reliable communication and processes among the care team
In addition to tracking measures of reliabiity for new processes (for example, percent of patients having delirium screening per shift), teams have found it useful to track outcomes measures like average days on ventilator and average length of stay in the intensive care unit.