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The trauma ICU has a variety of high-acuity and difficult conditions that can cause obstacles and hesitation to change sedation and mobility practices. How does the ABCDEF bundle apply to the trauma ICU? Dr. Gregory Schaefer joins us now to discuss his expertise and team’s success in practicing the ABCDEF bundle in the trauma ICU.

Episode Transcription

Kali Dayton 0:00
I have previously shared my experience and a meeting with a group of critical care leaders in which I shared the outcomes of the “Awake and Walking ICU”. I was repeatedly met with the argument quote, “Well, you don’t have trauma patients.” Unquote.

I am thrilled to address that in this episode. How does the ABCDEF bundle apply to the trauma ICU? Why is it so important to promptly implement interventions that will help prevent and treat delirium and IC acquired weakness during trauma rooted critical illness? How can we do so safely and quickly? Dr. Gregory Schaefer joins us now to share his insights and expertise into the ABCDEF bundle in the trauma ICU. Dr. Schaefer, thanks for coming on the podcast. Can you introduce yourself to our listeners?

Dr. Shaefer 1:28
Sure. Good afternoon. My name is Greg Shaffer, I’m a trauma and critical care surgeon at West Virginia University and the medical director of surgical critical care.

Kali Dayton 1:39
And how did you get interested in the ABCDEF bundle? Or how did that come and become intertwined with your trauma expertise?

Dr. Shaefer 1:48
Sure, I’ve always had a great interest in quality improvement within the ICU when the ICU liberation collaborative, the eighth riff bundle was first put out as a concept really by Wes Ely brand upon a variety of just amazing leaders in critical care put forth the invitation through SCCM for any interested institutions to begin participation in the collaborative, that would implement the A through F bundle in their ICUs and look to see how it impacted outcomes.

Kali Dayton 2:21
And I’m especially excited about this, because I remember sitting in a collaborative meeting with a bunch of different specialties of ICAO and I was presenting some case studies about the this awakened walking ICU and one of the main critical care leaders actually became very defensive and said, Well, you don’t have trauma patients. So that really intrigued me. And from your experience, even from the very beginning of the ABCDEF bundle, how have you seen the A to F bundle apply to the care of trauma patients?

Dr. Shaefer 2:55
Really, it’s essential with trauma patients, we have really a mixed population of ages. And so we’ll have younger patients who present to us with injury related mobility challenges in the older population, they may have developed some frailty that led to their injury that compounds the challenges of mobility.

Additionally, in the trauma pipe trauma population, we have patients that may be challenged by substance use disorders, that makes it more challenging to effectively manage their pain, their sedation, their agitation, and then in the older population, neurologic injuries, it does make it more challenging when we’re dealing with some underlying dementia. So really having a broad spectrum of ages introduces a broad spectrum of challenges. But fortunately, the A through F bundle is flexible enough that it allows us to accommodate the needs of all those patients.

Kali Dayton 3:52
Absolutely. And I think sometimes we really misunderstand the use of sedation in the ICU, some people will say, well, our patients have a lot of pain, as if you can’t minimize sedation because of their pain. So how do you apply the ABCDEF bundle to patients trauma patients that are suffering from severe levels of pain, and help prevent delirium and all those things?

Dr. Shaefer 4:17
Sure. It’s really been a comprehensive effort from nursing, physical therapy pharmacy, our physicians and mid level providers, everyone that’s involved respiratory therapy, really adopting this concept of we are going to be used utilizing an analogous sedation really with a analgesia first premise, and that entails being diligent in our assessments of pain every four hours, making sure that we’re utilizing the appropriate tool that has been validated and we know now that CPOT has been validated in patients with TBI. And we’ve actually had to go the other direction as well.

We’ve probably expanded our use of the NRS- numeric rating scale, because a lot of patients prior to this, we were saying, “Well, they’re intubated. We can’t get a reliable pain exam”. When in fact, even if you are intubated, we’ve had patients that were quadriplegic where they’ve used a straw with their mouth to point to a number on a board to indicate their pain. Patients can hold up digits that correspond with their pain, write down their pain, so we’ve become better at assessing pain.

And simultaneously, we’ve done a better job of recognizing that patients with effective pain management typically need less sedation, and that’s required a paradigm shift. For all of our providers, nurses, pharmacists, APPs, physicians. We’ve expanded our use of non-narcotic analgesics, acetaminophen, ibuprofen, naproxen, topical agents such as diclofenac gel, lidoderm, or lidocaine patches, expanded our use of ketamine, as well as partnering with our regional pain providers to utilize neuraxial anesthesia, erector spine, a blocks epidural catheters, and that’s really allowed us to dramatically improve or decrease the amount of sedation that our patients need.

Kali Dayton 6:21
And this is so exciting and fascinating to me, because coming from an MSICU, that rarely sedates patients and rarely has even fentanyl drips going, it’s been a little bit hard for me to understand how in other ICUs, automatically, fentanyl drips are started sometimes at very high rates. Without the patient being able to report their pain. I appreciate having patients tell me what they need, so I can treat it appropriately and to satisfaction and to comfort. Otherwise, it feels like we’re just guessing and when you have agitation. How do you know what it’s from? So how has it benefited your team to be able to have patients tell you what they need? You know, you mentioned that you decreased your narcotic use. But do you feel like pain is more appropriately treated? And are they more immobile because they’re in less pain?

Dr. Shaefer 7:12
I think they may still have similar amounts of pain, but we’re more effective in managing that. And that is achieved through a through multiple approaches. Number one is educating patients and families about pain, explaining to them different types of pain that they’re nociceptive and neuropathic pain and how we treat that helping our patients to understand that they are our partners in managing their pain, that we are going to work with them, we are going to believe them and listen to them that empowers the patients and the families.

And I believe that gives them more confidence that they will cooperate with being mobilized if they’re confident that we can help to manage their pain. During our procedures, we have a pre-procedural HUDDLE, where we talk about what our anticipated pain management is going to be during that case, we know that procedures are the most pain associated process in the ICU. And that can be anything from turning to central lines to chest tubes. And so being proactive and managing pain also gives our patients and families confidence that they can participate in activity and procedures.

Kali Dayton 8:24
That’s excellent. And when you’re using less narcotics for pain management, how has that impacted your delirium rates?

Dr. Shaefer 8:33
So we are working on developing or implementing a dashboard through our in collaboration with our electronic medical record right now. And so will we will be able to more objectively define our delirium rates. One of our greatest challenges throughout the last two and a half years has certainly been the turnover in nursing and the impact on experience. So we are frequently having to reinforce re educate remind providers about utilization of delirium assessment, anecdotally, I can say that we have less delirium, one of our trauma. Well, it’s probably not unique to trauma patients, but practicing in a state with one of the highest levels of substance use disorder in our population. We noticed that that contributes to delirium because we have substance abuse, withdrawal, or substance use withdrawal amongst our patients frequently.

Kali Dayton 9:32
And how is decreasing delirium impacted workload? I know we’re talking to anecdotal if this stuff hasn’t, the rates haven’t been tracked, but does a hazard team notice a change in workload with the decrease in delirium?

Dr. Shaefer 9:47
It seems that nurses are able to spend more time dressing changes, interacting with patients and families being proactive rather than constantly trying to respond to the delivery In amongst the patients. But one of the other things that we really want to track is the read, hopefully, we’ll see the manifestation of our efforts in a reduction in restraint use. And I think that will be important because if we have our patients pain managed effectively, and we have done everything possible to prevent and mitigate delirium that will go a long way towards reducing delirium. And, you know, we know from from Brendon Weston’s paper that everything got better, the more you implemented the bundle elements.

Kali Dayton 10:35
And your team participated in that initial study, correct?

Dr. Shaefer 10:38
Yes,

Kali Dayton 10:40
So you also had those improved outcomes.

Dr. Shaefer 10:43
We did. And that was, it was wonderful to see. And it really, that was a bottom up and top down process simultaneously, we presented to our hospital leadership, the premise of the A through F bundle and what it promised and obviously they were intrigued and excited at the prospect, and were incredibly supportive. So Mr. Wright, our hospital president, his support was instrumental in helping us to move forward. And having buy in at the pointy end of the stick from the nurses, the RTS, the physical therapist really was also important. And seeing those those results of decreased ventilator length of stay decreased ICU length of stay, all of those are exciting. And even five years later, that process of looking at implementation related improvements is ongoing.

Kali Dayton 11:39
And so I think a lot of clinicians that work in trauma are gonna say, That sounds really nice. Those are really nice theories, that probably works for some patients. But what about the exceptions that always comes up? How do you know when a patient actually needs sedation, especially deep sedation, what kind of exceptions exist in the trauma realm?

Dr. Shaefer 11:58
So one of our opportunities to dive a little bit deeper into these situations is amongst traumatic brain injury patients. And really, we’ve seen a shift in the last few years that the majority of our patients we’re trying to keep as light as possible in terms of the depth of their sedation, so that we can obtain those frequent neurologic examinations. There are a few patients who have uncontrollable intracranial hypertension, that may not be appropriate for decompressive craniectomy where we do need to use a deeper sedation. But that being said, we partner with our neurosurgeons and neurocritical care intensivist and make an effort to get that patient as deep as we need to in order to control the ICPs. But see, at least daily if there’s an opportunity to lighten things up and perhaps even get a neurologic exam.

Kali Dayton 12:56
And how do you continue to apply the A to F bundle as far as choosing the sedatives.

Dr. Shaefer 13:02
So it has been, I can count on one hand the number of times that we’ve had a patient on a benzodiazepine infusion in the surgical ICU in the last five years. Certainly there are situations where it’s appropriate your Status Epilepticus patient, your patient that perhaps has a history of benzodiazepine exposure, severe traumatic brain injury patient who needs something less hemodynamically active than dexmedetomidine or propofol.

So it’s not to say that we’ve thrown the baby out with the bathwater, but we’ve certainly become far more selective. In the patients where we utilize a benzo infusion. Our transition has been almost exclusively to dexmedetomidine infusions and propofol infusions. We usually have a conversation at the time of admission, which agent is most appropriate for that? Certainly their respiratory status is a major factor in determining which is appropriate. But we also take into account their hemodynamic status coexistent injury burden and their overall cardiac status.

Kali Dayton 14:12
And then how do you determine…. what’s your process of determining when to liberate patients from sedation? And what’s your process of awakening trials?

Dr. Shaefer 14:22
Absolutely, this is something that I’m passionate about. And we’re actually revisiting this right now. Our patients who are on continuous sedation will have each morning a spontaneous awakening trial that begins with a screening process and this was recorded in our electronic medical record where we can see each of the elements of the screening process if they are appropriate to undergo the SAT that’s completed and then they’ll move on to the SBT spontaneous breathing trial.

And these really mirror the great work that was done by Dr. Tim Girard and his colleagues really seminal paper on this topic then the next step is the spontaneous breathing trial again a screening process and we’re actually implementing in the next month or two a process at the bedside where a paper will go up on the board and we’ll be able to document: Did they screen positive to proceed for an SBT? When was it started? When was it completed and who was notified? and our benchmark is going to be 80% of patients extubated within two hours of passing an SBT.

We typically round as a team three times a day. The traditional daily rounds that occur at eight or nine in the morning. There’s a transition rounds at 530 at night between the daytime and nighttime covering team and then the nighttime will make some rounds usually between 11pm and 1am. And so we are it should be automatic that patients every morning have an SBT screen performed if they’re on a ventilator, but we’re reinforcing that with the paper it’s got a giant letter B and red in the center of it to remind everybody that this patient should be getting their SBT in the morning and then all of that is going into a tablo dashboards so we’ll be able to report out by unit and service how many patients had an SPT that should have had it done and how many were extubated within two hours of completing an SBT.

Kali Dayton 16:20
And now that your sedation is so minimized, how often do patients really have to have SATs?

Dr. Shaefer 16:26
It’s pretty infrequent, we will have a select group of patients kind of the short term intubated due to agitation that will oftentimes sedate with a dexmedetomidine or profile and we just have to we stop everything and then they get excavated rather than re initiating or getting them to deep unnecessarily. But the the frequency of doing SATs is has decreased over time. I don’t think it will ever get to zero because there always will be patients who are appropriate for a degree of light sedation or really, I don’t even know if sedation is the right word. They just need probably some more anxiety lysis and calming.

Kali Dayton 17:12
I love the way you just put that and when and what kind of wrath are you talking about when that’s the approach?

Dr. Shaefer 17:19
So the the target RASS when we started was zero to plus one we are I tell folks I’m happy with minus one sometimes up to plus one one and a half. And a lot of this is at the bedside we do the brain roadmap that that Dr. Ely talked about every morning so our nurses are engaged that’s actually how we start rounds every day is we go through the A through F bundle elements. And we say okay, when we get to choice of sedation, I describe it as fidgety. I say I’m okay with patients being fidgety because that tells me that they’re their neurons are connecting but I’m not okay with them doing anything that’s detrimental to their care, dislodging catheters, tubes, that sort of thing. So in order to put it into a term that most people can comprehend a little more easily I say titrate to fidgety or, or calm.

Kali Dayton 18:18
Oh, that is so nice to hear this. You put perfectly what I’ve been trying to say so often calm. I mean, I’m okay with movement. And I think that’s something that we’re culturally transitioning to an ICU community as a whole no matter the specialty. It sounds like the culture in your team has a deep understanding of RASS, what that really means that they’re actually accurate RASS assessments and scores happening and that there isn’t an expectation for them to be deeply sedated. Unless there’s a distinct exception, which is so nice to hear. And how has this impacted, over the years, the morale of your team and just the environment in general.

Dr. Shaefer 19:04
So when I took over as as the SICU director, one of my goals was to say, “I want our unit to be the place where everyone in the hospital wants to come to work.” We have engaged our nurses again by the brain roadmap and in true American fashion if A through F is good, more letters are better. So we’ve actually added some letters we’ve gone to and some of that is stolen a bit from the VAP bundle but we have G forget outlines tubes and drains H for head and bed elevation I is for inspect skin daily j is making sure that we’re jabbing them with DVT chemo prophylaxis I just haven’t been inspired yet to come up with more letters but there’s there’s still lots of time the one thing that we’re we’re most proud of we came in I said we need to engage our respiratory therapists even more than just with the SPT and so in the midst of COVID we develop what’s called the inspiratory. Pause. And so when the nurses finished their ICU brain roadmap, the respiratory therapist has their moment on the stage where they discuss what the ventilator settings are, and they can elaborate on the SPT. So really, the the A through if bundle has now improved morale, the nurses feel engaged. And they actually come to us when they have other services that are rounding in our unit. They notice when those services aren’t doing brain roadmap because they don’t feel as engaged in the care of that patient.

Kali Dayton 20:36
Oh, that is that just captures an interdisciplinary approach. And that’s the only way to really make all this happen. And you’re you’re mentioning or implying that the intensivists maybe the MDs, APPs, during rounds are taking leadership and guiding this discussion, or this is integrated into your rounding process. How did that happen? And how have you seen that benefit, the consistency of this approach?

Dr. Shaefer 21:04
This starts really with multiple levels. At the time, our nursing leadership, Miranda Newsom, and Zach Koshi. Were our SICU manager, clinical preceptor, they bought into this, and they really encourage staff to be engaged, we develop the laminated sheet that is at the bedside for the nurses to use as a guide at each time. Jerry Yoho, was our adult ICU director. And he supported this and that has helped us to get the message across to all of our adult ICUs.

And then identifying champions amongst the nurses, and this is in the ICU liberation textbook about having ground level support. And it’s not a matter of telling people to do something. It’s convincing people about the why, and showing them at the end that this has meaning and whether, you know, when when I took the course in Vanderbilt with Wes Ely, they had those videos of people that were ICU survivors, and seeing the why seeing those patients that come back and knowing that implementing the A through F bundle likely was a contributing factor to their success. And knowing this is something tangible the nurses can do and take ownership of his really engage them.

Kali Dayton 22:21
Oh, I’m just over here clapping while I’m on mute because this is so much of what I’ve been trying to capture in the podcast, I consistently say, “Until we find our why we cannot find our how.” And so I think that is very revealing that your team has had such success because everyone understands why and what they’re working towards. And then how to customize this for each patient? How does mobility come into play? What is the role of your rehab services? And how do you know when a patient is appropriate?

Dr. Shaefer 22:48
So on our trauma, admission orders and secure admission orders, we have a physical and occupational therapy console that is I guess, auto click, they’re pre selected for every patient. So PT and OT will evaluate that patient within the first 24 hours and begin the process of assessing what their mobility needs are, what their disposition needs will be. So that’s that’s a big step. Our physical therapists and occupational therapists have been engaged from the beginning, we’ve had some pilot programs instituting the Johns Hopkins higher level highest level of mobility process, and on top of that, we also built in a safety screen for mobility.

So that is in collaboration, the Duke moves, people put that in and really it’s a mobility screening assessment, similar to what we would do prior to an SAT and SBT. It’s an analog to that and allows us to identify if there’s any physiologic or medical barriers to safe mobility for that patient. We’re also fortunate to have some really engaged physical medicine and rehab physiatrist who come in on our especially our spinal cord and severe traumatic brain injury patients. And so every patient is seen within 24 hours to have an initial assessment, the physiatrist helped to develop a treatment plan while they’re here, and we engage families in exercise, you know, “These are things you can be doing when PT and OT is not here. Here’s some Thera bands. Here’s some things you can do with passive range of motion.”

Kali Dayton 24:20
Oh, I would love to tour your your unit. It just sounds like my cup of tea. I guess this is so much of how it should be. This is what we’re talking about. It’s exciting to see that applied to trauma that I wish I’d had you right next to me during that initial discussion to say this actually really applies to trauma. How have you seen this impact patient outcomes and survivorship? Do you have patients that you’ve kept in touch with Have you seen what have you seen?

Dr. Shaefer 24:45
So each year, we were disrupted like the rest of the world with COVID but we have our trauma night of recognition annually, and that’s where we have two adult patients and a pediatric patient. that come back. Usually they’ve been seriously injured critically ill, and they’ve survived. And we see that while the A through F bundle may not be the sole factor, we know that effective pain management, regular screening for delirium, minimizing sedation and early mobility are really the foundational factors that allow the other aspects of their care to be successful. We have fantastic orthopedic trauma surgeons who can stabilize an open book pelvic fracture and and acid tabula, but without that emphasis and daily assessment for mobility, that fantastic repairs for not.

Kali Dayton 25:42
Oh, such good points. And have you tracked any data as far as the impact to health care costs, I am going to include a study on the blog sharing significant impacts to health care costs for trauma ICUs, but the A to F bundle, but what have you seen within your team?

Dr. Shaefer 25:58
So we’ve not studied the financial impacts, I can imagine that they are positive- extrapolating from the data that we do have that our ICU and ventilator lengths of stay have decreased. Significantly, I actually just send an email yesterday to our quality folks and outlined about 15 specific data points that we want to see from their standpoint and how mobility and implementing are really I through air A through J bundle can impact that even more than just the original A through F elements.

Kali Dayton 26:35
Well keep us posted. If you ever had those data points, I’d love to share them because we love numbers, anything else you would share with the ICU community?

Dr. Shaefer 26:44
I really think that this is something that can be applied to any facility with critically ill or injured patients, whether you’re a four bed ICU, or will soon be over 100 adult ICU beds here. And so it’s about mentoring, having people that are excited, and invigorated at the prospect of using really pretty basic concepts to take good care of patients, we utilize a virtual critical care consults service here. And that’s allowed us allowed many of our smaller system hospitals to maintain their ICU through the pandemic. And we’re implementing and working to help them to learn about the A through F bundle, we are going to be investigating, we actually have some information coming in from SCCM, about beginning the ICU liberation course so that we can help to bring these important patient care elements to every facility in our health system that has an intensive care unit.

Kali Dayton 27:47
That is so exciting. And when I have teams from larger facilities reach out for training and consulting, that’s their vision as well. If we can establish it here, we can spread it throughout the system and imagine how many lives could be saved and benefited. That is your your team is spot on with your whole trajectory. And that’s so exciting to hear. We will include on the blog studies that you’ve mentioned, Girard, Dr. puns, Studies, Dr. E, Lee’s brain mapping work and anything else that you’d like to share. That’s A to F and trauma related. This will be available on the blog so everyone can go and do their own homework. And thank you so much. And if you have questions for Dr. Schaefer, let me know if we’re gonna keep picking his brain. It’s good to know we have a trauma expert that has mastered the A to F bundle within their own team. Thank you so much, Dr. Schaefer.

Dr. Shaefer 28:35
All right. Thank you

Transcribed by https://otter.ai

 

References

Clark, et al. (2013). Effectiveness of an early mobilization protocol in a trauma and burns intensive care unit: a retrospective cohort study. Physical Therapy and Rehabilitation Journal, 93(3). 

Falkenstein, et al. (2020). The economic and clinical imact of an early mobility rogram in the trauma intensive care unit: a quality improvement project. Journal of Trauma Nursing, 20(1). 

Girard, et al. (2008). Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (awakening and breathing controlled trial): a randomized controlled trial. Lancet, 371. https://pubmed.ncbi.nlm.nih.gov/18191684/ 

Hemphill, C. (2017). Improving outcome after intracerebral hemorrhage: maybe it is the body, not the brain. Neurocritical Care, 26. 

Higgins, et al. (2019). Early mobilization of trauma patients admitted to intensive care units: a systematic review and meta-analyses. Journal of Injury, 50(11). 

Pun, B., 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).

Shampo, et al. (2022). Using a real-time abcdef compliance tool to understand the role of bundle elements in mortality and delirium. Journal of Trauma Acute Care Surgery. https://pubmed.ncbi.nlm.nih.gov/35343926/ 

Sweeney, J. (2018). Impacting delirium in the trauma icu utilizing the icu liberation collaborative benchmark report. Jounral of Trauma Nursing, 25(6). 

 

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