The Legal Liabilities of Failing to Practice the ABCDEF Bundle

As a nurse and nurse advocate, I am passionate about protecting nurses and all ICU clinicians from falling victim to legal liabilities of their environment. The alarming reality is that when hospitals fail to train and support their teams in keeping patients as awake and mobile as possible, everyone from hospital administrators to bedside clinicians are vulnerable to legal liabilities.?

If hospitals are not practicing the ABCDEF Bundle, they are not complying with standard of care and are allowing significant risk and harm to happen to patients. The ABCDEF Bundle has been proven to provide patients the best opportunity to survive and thrive.?

Even at subpar compliance, it has proven to decrease:

• 7-day mortality by 68%
• Coma and delirium by 25-50%
• Readmissions to the hospital by 46%
• Discharge to anywhere but home by 36%

These outcomes are dose-dependent. The less sedation is given and more patients are mobilized, the better all of these outcomes are!?

We know that early mobility specifically decreases:

• Hospital-acquired pressure injuries
• Hospital-acquired infections
• Falls
• Delirium
• Long-term cognitive impairments
• Long-term physical disability

We know that the avoiding sedation decreases:

• Death
• PTSD
• Chronic brain injuries
• Physical disability
• Time on the ventilator
• Discharges to care facilities
• Time in the ICU

The ABCDEF Bundle was implemented into many Intensive Care Units (ICU) throughout the United States between 2016-2019.

?Unfortunately, in many units, the only evidence of the ABCDEF bundle today is in charting prompts in the electronic health record (EHR).?

So, what are the legal liabilities when an ICU team fails to provide this evidence-based care??

In episode 179 of the podcast, “Walking Home From the ICU”, I interviewed Maggie Ortiz, RN, MSN , who is an expert nurse advocate.?

I was shocked to learn that hospitals, leadership, and clinicians are vulnerable to the following charges:

False Documentation

Certain elements of the ABCDEF Bundle are required in the EHR. Yet, commonly, the charting is not accurate and can be considered false documentation.?

RASS:

The Richmond Assessment Sedation Scale is a tool to measure patients’ psychomotor activity and is most often used to titrate sedation.? For example, when a provider orders a continuous sedative drip it is usually ordered for a RASS score rather than a certain dose of sedation.?

Thanks to the past ABCDEF Bundle initiatives by the Society of Critical Care Medicine, most sedation order sets have a preset RASS score range of 0 to -2. This means that patients are somewhere between completely awake to sedated to the point of being able to open their eyes to voice and make eye contact for less than 10 seconds. RASS should be charted every 2-4 hours and PRN for patients on continuous sedation or analgesia.

As I have teams perform manual audits, they compare the prescribed RASS to the documented RASS to the actual RASS the auditors observe at the bedside. Among the numerous teams that have provided me with their audit results, 50-80% of their documented RASS scores are inaccurate. About 60% of those inaccurate scores are at least 2 points too high.?

This means that nurses are charting a RASS that reflects light sedation when patients are actually deeply sedated. This is false documentation similar to charting fake vital signs.?

CAM-ICU:

The Confusion Assessment Method is a powerful tool to diagnose ICU-delirium. This is the equivalent of a creatinine to assess for renal function.?

Depending on the facility and state, CAM screening is required to be done and documented 1-3 times every 24 hours.?

Some teams may seem to have high rates of compliance with CAM charting. Yet, upon further investigation, it is very common to see “UTA” charted, which means, “Unable to Assess”.?

If a nurse documents a RASS of “-2” and “UTA” for CAM, this may be a sign of false documentation. The only valid possibility is that the patient does not speak english. Otherwise, the patient is sedated deeper than a RASS of -2 and the RASS score is falsified, or the nurse did not perform the CAM. This is false documentation.?

It is also very common for nurses to not perform the CAM but base their documentation off of a patient’s ability to follow commands. This is also false documentation. This can be considered equal to falsifying a lab value.?

Mobility Screening:

Mobility screening is required in the EHR to document a patient’s level of mobility. It is usually required every 12 hours. It may look compliant if there is any charting present. A closer look often reveals “bedrest” documented for most patients in the ICU. When a patient’s true mobility level is not “bedrest”, and there is no contraindication to mobility, this can be considered false documentation.?

SAT:

Spontaneous awakening trials (SAT) is the process of turning sedation and analgesia OFF to assess for continued necessity of sedation and analgesia. This should be done at least every 24 hours unless there is a contraindication. This is charted as “pass” or “fail”.?

If an SAT is charted as “failed”, but there is no sign of sedation being turned off, this may be a sign of false documentation.?

If it is documented that an SAT was “failed” and the reason was “agitation”, yet the highest RASS is +1 (restlessness), this may be false documentation.?

SBT:?

Spontaneous breathing trials (SBT) is when adjustments are made to the ventilator to allow the patient to take their own spontaneous breaths with minimal to no support from the ventilator. This is assessing for the patient’s readiness to be off of mechanical ventilation.?

If an SBT is failed, the respiratory therapist is obligated to document which criteria is unmet. It has been observed that this documentation can be falsified with answers that are untrue and do not apply to the patient. This can be false documentation.?

Practicing Medicine Without a License

Administering More Medication than is Prescribed

When nurses sedate patients to a RASS lower than is prescribed, they are giving more medication than is prescribed. These can be controlled substances such as opioids and benzodiazepines. This is practicing medicine without a license.?

One study showed that despite an ordered RASS of -3, 70% of patients were deeply sedated to a RASS of -4 and -5. This is alarming considering that deep sedation is an independent predictor of death. We see this trend in the research that though the charted RASS scores were similar between day and night shift, the doses of sedatives and opioids were increased at night. This is likely false documentation.

When an SAT is failed, most hospital policies require nurses to resume the sedation at half the previous dose. It can be common cultural practice to resume the sedation at the previous dose, and sometimes even increase the dose. This is giving more medication than is prescribed and practicing outside the RN scope of practice and against hospital policies.?

Failure to Assess

RASS

When RASS documentation is not performed, this is a failure to assess. High risk and controlled substances are being given without monitoring and/or accurate doses.?

CAM-ICU

In some ICU teams, CAM-ICU has 0% documentation. This means that patients are not being screened and assessed for acute brain failure. Considering that delirium doubles the risk of dying in the hospital, this failure to assess is dangerous to patients and a significant liability for hospitals and clinicians.?

Failure to Treat

Delirium

ICU teams are not trained to adequately treat delirium. This results in a failure to treat delirium with the proper interventions such as avoiding medications that cause delirium, facilitating real sleep, family engagement, and mobility. Instead, when patients demonstrate symptoms of delirium such as restlessness, anxiety, confusion, and impulsiveness they are given more deliriogenic sedatives. Giving sedation in response to delirium could be likened to giving bacteria for sepsis. Yet, in the ICU, it is common practice and culturally acceptable to respond to delirium with sedation.?

ICU-Acquired Weakness (ICUAW)

Patients quickly lose muscle mass and function in the ICU while sedated and immobilized. This leads to the life-threatening condition of ICU-acquired weakness. ICU teams are not trained to prevent and treat this condition. When signs of this are observed such as limb weakness and failed SBTs, the response is to resume sedation and/or keep patients in bed. The proper treatment for ICUAW is to initiate mobility but the cultural response is to chart “bedrest” as their level of mobility and to avoid mobility. This can be considered a failure to treat.?

Mobility:

Physical and occupational therapists face significant challenges to providing their services in the ICU. If they are fortunate to be consulted, they still face barriers of sedation and lack of interdisciplinary collaboration. It is common for nurses to tell physical and occupational therapists, "This patient cannot be mobilized". Culturally, nurses have the final say in many ICUs.

Yet, physical and occupational therapists have their master and doctorate degrees and are specialized in early mobility. If they were to be questioned about not mobilizing a patient that they were consulted on, would "The nurse wouldn't let me." hold up in court? Would they be held liable as well for failing to prevent, assess, and treat delirium and ICU-acquired weakness?

Elder Abuse:?

As our patient population in critical care continues to age, we must provide age-friendly treatment. Automatically sedating and immobilizing geriatric patients does not comply with the 4M initiatives being rolled out throughout our healthcare system. Administering benzodiazepines, deep sedation, failing to prevent, screen for, and treat delirium, and immobilizing vulnerable geriatric patients may not fare well in the courts.?

Conclusion:

These poor practices are done in ignorance. Culture is a powerful and blinding force that stops from questioning what is right and best. Even after working in an Awake and Walking ICU, I fell into the same harmful practices as my colleagues when I worked in other ICUs.?

Clinicians deserve to be educated and empowered to provide best practices. When a hospital culture does not allow and encourage best practices, everyone is at risk of being held legally liable.?

It is terrifying to realize that major auditing organizations as well as local leadership are unaware of the importance, impact, and liabilities of complying with the ABCDEF Bundle.?

What if reimbursement agencies realized that failing to practice the bundle was increasing costs by 30%?

What if survivors knew? What if the many survivors such as Suzanne held the hospital liable for the 13 extra days on the ventilator, delirium, ICU-acquired weakness, and permanent PTSD and cognitive impairments she has suffered??

What if Jim sued the hospital for the preventable 3 months in the ICU/LTACH, tracheostomy, PTSD, cognitive impairments, and physical disability??

In the near future, there may be an awakening to reality. When the world realizes that what is “normal” is not right.

?Will your team be at the leading front and already practicing the ABCDEF Bundle?