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Reducing Iatrogenic Risks: ICU-Acquired Delirium and Weakness—Crossing the Quality Chasm

Eduard E. Vasilevskis, MD; E. Wesley Ely, MPH, MD, FCCP; Theodore Speroff, PhD; Brenda T. Pun, RN, MSN, ACNP; Leanne Boehm, RN, MSN, ACNS-BC; Robert S. Dittus, MPH, MD
Author and Funding Information

From the Geriatric Research Education and Clinical Center (Drs Vasilevskis, Ely, Speroff, and Dittus), the Clinical Research Training Center of Excellence (Dr Vasilevskis), Veterans Affairs, Tennessee Valley Healthcare System; and the Department of Medicine (Drs Vasilevskis, Ely, Speroff, and Dittus), the Center for Health Services Research (Drs Vasilevskis, Ely, Speroff, and Dittus, and Ms Pun), the Division of General Internal Medicine and Public Health (Drs Vasilevskis, Speroff, and Dittus), and the Division of Allergy, Pulmonary, and Critical Care Medicine (Dr Ely and Ms Boehm), Vanderbilt University Medical Center, Nashville, TN.

Correspondence to: Eduard E. Vasilevskis, MD, Vanderbilt University Medical Center, 1215 21st Ave, S, 6006 Medical Center East, NT, Nashville, TN 37232-8300; e-mail: eduard.vasilevskis@vanderbilt.edu


For editorial comment see page 1034

Funding/Support: Dr Vasilevskis was supported by the Veterans Affairs Clinical Research Center of Excellence and the Geriatric Research Education and Clinical Center, Veterans Affairs, Tennessee Valley Healthcare, Nashville, TN.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2010 American College of Chest Physicians


Chest. 2010;138(5):1224-1233. doi:10.1378/chest.10-0466
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ICUs are experiencing an epidemic of patients with acute brain dysfunction (delirium) and weakness, both associated with increased mortality and long-term disability. These conditions are commonly acquired in the ICU and are often initiated or exacerbated by sedation and ventilation decisions and management. Despite > 10 years of evidence revealing the hazards of delirium, the quality chasm between current and ideal processes of care continues to exist. Monitoring of delirium and sedation levels remains inconsistent. In addition, sedation, ventilation, and physical therapy practices proven successful at reducing the frequency and severity of adverse outcomes are not routinely practiced. In this article, we advocate for the adoption and implementation of a standard bundle of ICU measures with great potential to reduce the burden of ICU-acquired delirium and weakness. Individual components of this bundle are evidence based and can help standardize communication, improve interdisciplinary care, reduce mortality, and improve cognitive and functional outcomes. We refer to this as the “ABCDE bundle,” for awakening and breathing coordination, delirium monitoring, and exercise/early mobility. This evidence-based bundle of practices will build a bridge across the current quality chasm from the “front end” to the “back end” of critical care and toward improved cognitive and functional outcomes for ICU survivors.

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