A feasibility study of a randomised controlled study of the Awakening and Breathing trial Coordination; Delirium monitoring and management; and Early exercise and mobility (ABCDE) bundle to improve functional and cognitive capacity in ventilated critically ill patients

Awakening and Breathing Trial Coordination- at 08.30 every day following a safety assessment: A. The mechanically ventilated patient will undergo a spontaneous breathing trial daily. B. The mechanically ventilated patient receiving a continuous sedative infusion will receive both a spontaneous awakening trial (SAT) and spontaneous breathing trial (SBT) daily. C. An ICU Registered Nurse (RN) will perform the spontaneous awakening and breathing trial. D. The Consultant Intensivist will make the decision to extubate the patient. Delirium monitoring and management: Every patient admitted to the ICU will undergo routine sedation and delirium assessment using standardized and validated assessment tools including Richmond Agitation and Sedation Scale (RASS) and Confusion Assessment Method (CAM) -ICU. B. An RN will perform and record the results of the (RASS) every 4 hours. C. An RN will perform and record the results of the Confusion Assessment Method-ICU (CAM-ICU) twice per day (tested at 08.00 and 20.00). D. Each day during multidisciplinary rounds, the team will set a “target” RASS score for the patient to be maintained at for the following 24 hours. E. Each day during multidisciplinary rounds, the team will use the acronym “THINK” if a patient is CAM positive (delirious). Toxic situations and medications Hypoxemia Infection/sepsis (nosocomial), inflammation, immobilization Non-pharmacological interventions (see below) K+ or other electrolyte interventions F. The multidisciplinary team will employ non-pharmacologic interventions when treating a delirious patient including: 1. Eliminate or minimize risk factors Administer medications judiciously; treat infections, treat dehydration and electrolyte disturbances,provide adequate pain control, maximize oxygen delivery , use sensory aids as appropriate, provide adequate nutrition 2. Provide a therapeutic environment Foster orientation, caregiver identification; explain all activities; communicate clearly, provide appropriate sensory stimulation, adequate light; one task at a time; noise-reduction strategies. Facilitate sleep Foster familiarity, bring familiar objects from home; Maintain consistency of caregivers; minimize relocations Maximize mobility: avoid physical and chemical restraints; ambulate or mobilize patient early and often Communicate clearly, reassure and educate family Consider psychotropic medication only as a last resort Early mobility and exercise A. Patients are candidates for mobilization and exercise when the following (minimum) safety criteria are met: M – Myocardial Stability * No evidence of active myocardial ischaemia in the last 24 hours * No dysrrhythmia requiring the administration of a new antiarrhythmics in the last 24 hours O – Oxygenation adequate on: * FiO2< 0.6 * PEEP < 10 cm H2O V – Vasopressors minimal * No increase dose of any vasopressor infusion for at least 2 hours E – Engage to Voice * Patients who do not respond to verbal stimulation (RASS 4-5) – Passive range of motion * Patient responds to verbal stimulation (i.e. RASS > -3) – Early mobility and exercise S – Safety * Not receiving therapies that restrict mobility (open-abdomen) * No injuries in which mobility is contra-indicated (e.g. unstable fractures) B. Any other justification for not implementing the protocol must be documented specifically by the Consultant Intensivist. C. The registered nurse can assess the patient's readiness for mobility in consultation with a physiotherapist if this service is available. Otherwise, the Registered Nurse will assess whether the patient meets the mobilization and exercise criteria. D. Each patient is assessed upon admission to the unit, and those who qualify immediately begin on the protocol. Those who are not eligible are reassessed daily at 08.30. If activity has been halted due to an acute event the patient is re-evaluated each day until the protocol can be reinstated. E. Each eligible patient is encouraged to be mobile at least once a day, with the specific level of activity geared to his or her readiness. Patients progress through a four level process, embarking on the highest level of physical activity they can tolerate, as outlined below: Level 1: If unable to lift arm against gravity: * Passive range of motion three times per day (tested at 06.00, 13.00, 20.00) * Active resistance physiotherapy (tested at 10.00, 18.00) * Sitting position in bed 20 minutes three times per day (tested at 06.00, 13.00, 20.00) Level 2: If able to lift arm against gravity: * Passive range of motion three times per day (tested at 06.00, 13.00, 20.00) * Active resistance physiotherapy (tested at 10.00, 18.00) * Sitting position in bed 20 minutes three times per day (tested at 06.00, 13.00, 20.00) * Sitting on edge of bed daily (tested at 10.00) Level 3: If able to move leg against gravity: * Passive range of motion three times per day(tested at 06.00, 13.00, 20.00) * Active resistance physiotherapy (tested at 10.00, 18.00) * Sitting position in bed 20 minutes three times per day (tested at 06.00, 13.00, 20.00) * Sitting on edge of bed daily (tested at 10.00) * Active transfer to chair once per day Level 4: If able to move leg against gravity and managed Level 3 the previous day: * Passive range of motion three times per day (tested at 06.00, 13.00, 20.00) * Active resistance physiotherapy (tested at 10.00, 18.00) * Sitting position in bed 20 minutes three times per day (tested at 06.00, 13.00, 20.00) * Sitting on edge of bed daily (tested at 10.00) * Active transfer to chair once per day * Ambulation (marching in place, walking in ICU corridors etc)