Prolonged mechanical ventilation of patients in intensive care units across the United States consumes billions of health care dollars every year. Using the awakening and breathing coordination, delirium monitoring/management, and early mobility (ABCDE) bundle along with the Critical-Care Pain Observation Tool and the Richmond Agitation-Sedation Scale combines the best available evidence to optimize outcomes for critically ill patients. This study is the first to examine the effects of implementing the ABCDE bundle, the Critical-Care Pain Observation Tool, and the Richmond Agitation-Sedation Scale together in a coordinated effort across multiple disciplines. The aim of using this combination of evidence-based tools is to reduce ventilation time by reducing oversedation, decreasing the incidence of delirium, and improving pain management.

Mechanical ventilation (MV) for respiratory support remains a cornerstone of critical care medicine.1,2  Prolonged MV is associated with complications including barotrauma, ventilator-associated pneumonia, sepsis, pulmonary embolism, and pulmonary edema.3  Prolonged ventilation negatively affects quality of life,4  prolongs hospital stays, and increases the economic burden.5  Wunsch et al6  reported that for patients receiving MV in intensive care units (ICUs), the mean (SD) individual medical cost was $34 257 ($40 559), accounting for approximately \$27 billion in total health care costs each year in the United States. Recent clinical practice guidelines from the American College of Chest Physicians and the American Thoracic Society recommend avoiding prolonged MV by using protocols to minimize sedation in patients receiving MV.7

Extant literature assesses different approaches to weaning patients from MV.2,5,8  Current practice guidelines recommend using daily sedation vacations and spontaneous breathing trials, reducing the fraction of inspired oxygen before beginning breathing trials, and using the intermittent mandatory ventilation mode before attempting extubation to allow the patient to take breaths independent of the set ventilator rate.9  Despite these guidelines and recommendations, the issue of prolonged ventilation time persists.

Because of the adverse clinical, health, and economic outcomes of prolonged MV, interventions should be used to promote the patient’s well-being. The Neuman model allows the researcher to identify individual stressors that could negatively affect the patient and to create prevention strategies to decrease the impact on the patient’s health.10  This model also applies to patients in the ICU receiving MV. Some of the highest-ranked stressors in patients admitted to the ICU are fear of death, pain, needle sticks, confinement to bed by tubes or wires, and tube insertion into the mouth or nose.11  Each of these primary stressors is related to interventions used in the ICU. According to the Neuman model, eliminating or decreasing the number of stressors in a timely fashion can promote a healing environment. Optimal sedation and analgesia can alleviate anxiety, panic, and discomfort associated with MV by reducing the duration of ventilation.8  However, maintaining the appropriate balance of sedation and analgesia is challenging.12

Appropriate use and titration of sedation with the Critical-Care Pain Observation Tool (CPOT) (Table 1) and the Richmond Agitation-Sedation Scale (RASS) (Table 2) can prevent prolonged MV (Figure). The awakening and breathing coordination, delirium monitoring/management, and early mobility (ABCDE) bundle is a protocol that respiratory therapists and registered nurses can use to assess patients during sedation vacations and breathing trials for indications that extubation attempts have failed.15  The CPOT and RASS are parts of the ABCDE bundle, which is recommended by the Agency for Healthcare Research and Quality.16  Published literature supports the reliability and validity of the CPOT.17,18  The RASS is one of the most valid and reliable methods for measuring the quality and depth of sedation in adult patients receiving critical care.19,20

Using all available resources is mandatory to prevent oversedation, ensure successful extubation, and prevent reintubation or prolonged ventilation. However, previous studies have examined the effect of either the ABCDE bundle21  or sedation22  on ventilation time.

Our study objectives were to (1) determine if using the CPOT along with the RASS could reduce sedation time by treating pain instead of increasing the sedative dose and (2) use the ABCDE bundle to wean patients from ventilation. We used the rapid shallow breathing index (RSBI) and improved arterial blood gas values as indicators to wean patients from ventilation or determine the extubation time most likely to avoid reintubation.23  The RSBI is calculated during a spontaneous breathing trial by dividing the respiratory rate (breaths per minute) by the mean tidal volume (milliliters). In patients who otherwise meet criteria for extubation, an RSBI of less than 105 breaths/min/L indicates that successful extubation is likely (97% sensitivity).23  We used an RSBI of less than 105 breaths/min/L because this value was validated in the original study and in 2 subsequent validation studies.

### Data Collection

This study was conducted at a teaching hospital with a 34-bed ICU and included patients in neurosurgical, medical, and surgical (except cardiovascular surgery) ICUs. The ABCDE bundle was used to organize daily processes performed by the staff. The protocol provided structure and guidelines for sedation titration, sedation vacations, and daily procedures for weaning patients from ventilation. Per international guidelines,9  non-benzodiazepine sedatives, such as propofol and dexmedetomidine, were used for sedation. Intravenous opioids, such as morphine and fentanyl, were used for analgesia. Intravenous acetaminophen or ketorolac was occasionally used to decrease the amount of opioids administered. The CPOT and RASS were used to provide appropriate treatment and prevent oversedation, differentiating between pain and agitation.

The ABCDE bundle was implemented on February 1, 2018, after the institutional review board granted approval for the study. Sedation level, pain scales, and vital signs were evaluated hourly. The ABCDE bundle was performed daily (usually during morning rounds). The staff recorded the following data from March to April 2018: intubation date and time, time sedation was initiated, RASS and CPOT scores for titrating sedation and pain medication, daily awakening trials, daily spontaneous breathing trials with the RSBI, time sedation was discontinued, and extubation time. We conducted a thorough chart review for each patient admitted to the medical ICU. The review included time each patient spent receiving MV, being intubated, and requiring sedation. After we obtained all information from the chart review, we compared chart data with the data collection sheets completed by ICU staff.

### Study Participants

Participants eligible for the study required MV and were at least 18 years of age. Patients were intubated in the field by an emergency medical service, in the emergency department, or in the hospital during admission. We included only patients who were unable to self-report pain and had intact motor function. Patients dependent on home ventilators, those undergoing extubation because of a terminal condition, and those who required MV but were transferred to another facility (without the ability to continue to track data) were excluded. We excluded patients with brain injuries because the CPOT is not valid in these patients.

### Study Variables

Duration of ventilation was calculated by intubation and extubation time. Duration of sedation, primarily propofol, was the time between initiation and discontinuation (usually during sedation vacation) before extubation. These variables were measured for each admitted patient before and after the intervention period.

### Statistical Analysis

We performed retrospective analysis before bundle implementation for patients admitted to the ICU from February 1, 2017, to April 30, 2017, and after bundle implementation for those admitted from February 1, 2018, to April 30, 2018. We measured the rate of staff compliance with the ABCDE bundle, changes in number of ventilator days, and mean days of sedation before and after bundle implementation. All analyses were conducted with spreadsheet software (Microsoft Excel). P values less than .05 were considered statistically significant. A 2-tailed t test was used to analyze the data.

Demographics of the patients included in the study are shown in Table 3. After implementation, our nursing staff bundle compliance rate was 76.5%. After ABCDE bundle implementation, mean ventilation time significantly decreased by nearly 50% (a difference of 1.98 days). The decrease in ventilation time was observed among all patients. Using the ABCDE bundle reduced sedation time by almost 50% (a difference of 1.93 days), although this finding was not significant (Table 4). Of the 34 patients included in the postintervention phase of the study, 1 required reintubation within 24 hours. None of the remaining 33 patients were readmitted within 30 days of hospital discharge or reintubated within 30 days of extubation.

To our knowledge, this study is the first to examine the implementation of the ABCDE bundle together with the CPOT and RASS in the United States. Because conducting a randomized controlled trial was not feasible, we used a before-and-after study design to eliminate intervention bias between patients. Protocol-directed sedation and use of the CPOT and RASS reduced ventilation time, consistent with findings of previous studies21,22  in which the use of an analgesia and sedation protocol was associated with reduced levels of sedation and shorter mean ventilation durations.

Implementation of the ABCDE bundle was intended to decrease patients’ time receiving ventilation. The guideline was a reminder to implement daily sedation vacations and ventilator weaning, to provide a choice between analgesic or sedative medications, to be alert for delirium, and to promote early mobility. The components of the ABCDE bundle provided critical care providers with steps to discontinue sedation and MV for patients as early as possible.

The ICU staff members met all criteria except implementing early mobility while patients were receiving MV. Although all of the patients in this study received 30 to 45 minutes of physical therapy while receiving MV, ICU staff members voiced concern about the limited resources available to assist with early ambulation for these patients. These resources include ventilators designed for patient ambulation and mobility chairs. The ICU staff is working with physical therapists to provide additional ways (within existing financial constraints) to implement early mobility for patients receiving MV. Of the 34 patients enrolled in the study after bundle implementation, 3 were taken for ambulation for more than 10 steps and 12 were assisted to stand and transition into a bedside mobility chair. Pre-implementation mobility data are not available because early ambulation was not a documentation requirement before this study was conducted.

The implementation of the CPOT and RASS together gave critical care nurses a guideline to use when patients exhibited pain or agitation while receiving ventilation. Using the 2 tools together allowed the staff to either treat pain or titrate sedation on the basis of each patient’s physiologic signs. Nursing staff reported that at times the CPOT helped them identify physiologic signs indicating pain rather than agitation, which would have required up-titration of the sedative dose. Staff members were concerned about the lack of pain medication orders for some sedated patients. In these cases, staff members were directed to use their clinical judgment and treat according to each patient’s symptoms and clinical condition.

Most intubated patients stayed in the study once enrolled. However, our findings should be interpreted in light of limitations. The noncontrolled design of this study raises the possibility of confounding variables that may have influenced study outcomes. Because our study did not include patients with brain injuries, our findings may not be generalizable to neurological or trauma ICUs that care for patients with these injuries. Furthermore, our study cannot be generalized to long-term ventilator care units. Terminally ill patients who were extubated were also excluded from the study. The purpose of this study was to implement an international guideline, so our findings should not be considered definitive until randomized controlled studies validate our results. Our study included only adults, and the results should not be extrapolated to children.

Implementation of an evidence-based protocol (the ABCDE bundle for ventilator weaning and the combination of the CPOT and RASS for sedation weaning) dramatically decreased the time patients underwent MV. Despite a nursing staff compliance rate of 76.5%, our data reveal that twice as many patients had a positive outcome after implementation. Continued staff education and permanent implementation of these protocols could continue to decrease ventilation and sedation times for patients in the ICU, resulting in substantial cost savings and successful patient outcomes.

1
Marini
JJ
.
Mechanical ventilation: past lessons and the near future
.
Crit Care
.
2013
;
17
(
suppl 1
):
S1
.
2
Weled
BJ
,
LA
,
Hodgman
TM
, et al
Task Force on Models for Critical Care
.
Critical care delivery: the importance of process of care and ICU structure to improved outcomes: an update from the American College of Critical Care Medicine Task Force on Models of Critical Care
.
Crit Care Med
.
2015
;
43
(
7
):
1520
1525
.
3
Klompas
M
.
Complications of mechanical ventilation— the CDC’s new surveillance paradigm
.
N Engl J Med
.
2013
;
368
(
16
):
1472
1475
.
4
Huttmann
SE
,
Magnet
FS
,
Karagiannidis
C
,
Storre
JH
,
Windisch
W
.
Quality of life and life satisfaction are severely impaired in patients with long-term invasive ventilation following ICU treatment and unsuccessful weaning
.
Ann Intensive Care
.
2018
;
8
(
1
):
38
.
5
K Szilágyi
A
,
Diószeghy
C
,
Fritúz
G
,
Gál
J
,
Varga
K
.
Shortening the length of stay and mechanical ventilation time by using positive suggestions via MP3 players for ventilated patients
.
Interv Med Appl Sci
.
2014
;
6
(
1
):
3
15
.
6
Wunsch
H
,
Linde-Zwirble
WT
,
Angus
DC
,
Hartman
ME
,
Milbrandt
EB
,
Kahn
JM
.
The epidemiology of mechanical ventilation use in the United States
.
Crit Care Med
.
2010
;
38
(
10
):
1947
1953
.
7
Ouellette
DR
,
Patel
S
,
Girard
TD
, et al
.
Liberation from mechanical ventilation in critically ill adults: an official American College of Chest Physicians/American Thoracic Society clinical practice guideline: inspiratory pressure augmentation during spontaneous breathing trials, protocols minimizing sedation, and noninvasive ventilation immediately after extubation
.
Chest
.
2017
;
151
(
1
):
166
180
.
8
Devlin
JW
,
Skrobik
Y
,
Gelinas
C
, et al
.
Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU
.
Crit Care Med
.
2018
;
46
(
9
):
e825
e873
. doi:
9
Davidson
AC
,
Banham
S
,
Elliott
M
, et al
BTS Standards of Care Committee Member, British Thoracic Society/ Intensive Care Society Acute Hypercapnic Respiratory Failure Guideline Development Group, on behalf of the British Thoracic Society Standards of Care Committee
.
BTS/ICS guideline for the ventilatory management of acute hypercapnic respiratory failure in adults
.
Thorax
.
2016
;
71
(
suppl 2
):
ii1
35
.
10
Neuman
BM
,
Fawcett
J
, eds.
The Neuman Systems Model
. 5th ed.
Boston, MA
:
Pearson
;
2011
.
11
Kaur
M
,
Patidar
AB
,
Kaur
J
,
Sharma
SK
.
A comparative study of the patients’ and staff nurses’ perception of environmental stressors in ICU at a tertiary care hospital in Punjab, India
.
Int J Nurs Educ
.
2013
:
5
(
2
):
114
117
.
12
Wunsch
H
,
Wagner
J
,
Herlim
M
,
Chong
DH
,
Kramer
AA
,
Halpern
SD
.
ICU occupancy and mechanical ventilator use in the United States
.
Crit Care Med
.
2013
;
41
(
12
):
2712
2719
.
13
Gélinas
C
,
Fortier
M
,
Viens
C
,
Fillion
L
,
Puntillo
KA
.
Pain assessment and management in critically ill intubated patients: a retrospective study
.
Am J Crit Care
.
2004
;
13
(
2
):
126
135
.
14
Sessler
CN
,
Grap
MJ
,
Brophy
GM
.
Multidisciplinary management of sedation and analgesia in critical care
.
Semin Respir Crit Care Med
.
2001
;
22
(
2
):
211
226
.
15
Balas
MC
,
Burke
WJ
,
Gannon
D
, et al
.
Implementing the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle into everyday care: opportunities, challenges, and lessons learned for implementing the ICU Pain, Agitation, and Delirium Guidelines
.
Crit Care Med
.
2013
;
41
(9)(suppl 1)
:
S116
S127
.
16
Implementing the ABCDE bundle at the bedside
.
Agency for Healthcare Research and Quality website
. . Accessed October 19, 2018.
17
Keane
KM
.
Validity and reliability of the critical care pain observation tool: a replication study
.
Pain Manag Nurs
.
2013
;
14
(
4
):
e216
e225
. doi:
18
Buttes
P
,
Keal
G
,
Cronin
SN
,
Stocks
L
,
Stout
C
.
Validation of the critical-care pain observation tool in adult critically ill patients
.
Dimens Crit Care Nurs
.
2014
;
33
(
2
):
78
81
.
19
Ely
EW
,
Truman
B
,
Shintani
A
, et al
.
Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS)
.
JAMA
.
2003
;
289
(
22
):
2983
2991
.
20
Arevalo
JJ
,
Brinkkemper
T
,
van der Heide
A
, et al
AMROSE Site Study Group
.
Palliative sedation: reliability and validity of sedation scales
.
J Pain Symptom Manage
.
2012
;
44
(
5
):
704
714
.
21
Kram
SL
,
DiBartolo
MC
,
Hinderer
K
,
Jones
RA
.
Implementation of the ABCDE bundle to improve patient outcomes in the intensive care unit in a rural community hospital
.
Dimens Crit Care Nurs
.
2015
;
34
(
5
):
250
258
.
22
Faust
AC
,
Rajan
P
,
Sheperd
LA
,
Alvarez
CA
,
McCorstin
P
,
Doebele
RL
.
Impact of an analgesia-based sedation protocol on mechanically ventilated patients in a medical intensive care unit
.
Anesth Analg
.
2016
;
123
(
4
):
903
909
.
23
Habacon
GP
,
Tiglao
E
,
DeGuia
T
,
Del Poso
W
,
Limpin
ME
.
Rapid shallow breathing index rate as a predictor of weaning outcome during spontaneous breathing trial: a cohort study
.
Chest
.
2016
;
150
(4)(suppl)
:
303A
.

## Footnotes

The authors declare no conflicts of interest.