Common Challenges to Effective ABCDEF Bundle Implementation: The ICU Liberation Campaign Experience

Balas, Michele C.; Pun, Brenda T.; Pasero, Chris; Engel, Heidi J.; Perme, Christiane; Esbrook, Cheryl L.; Kelly, Tamra; Hargett, Ken; Posa, Patricia J.; Barr, Juliana; Devlin, John W.; Morse, Alexandra; Barnes‐Daly, Mary Ann; Puntillo, Kathleen; Aldrich, Janet; Schweickert, William D.; Harmon, Lori; Byrum, Diane; Carson, Shannon S.; Ely, E. Wesley; Stollings, Joanna L.

doi:10.4037/ccn2019927

Cited by 60 publications

(46 citation statements)

References 87 publications

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“…Support and engagement of senior health care executive can help secure and allocate the appropriate resources. The support of these groups is vital to the success of ABCDEF bundle implementation and function, as they can play an important role in motivating teams, helping to solve complex problems involving culture change within the hospital and ICU environment [93]. A summary of these and other commonly encountered barriers can be found in Table 2.…”

Section: Challenges To Bundle Implementationmentioning

confidence: 99%

The ICU Liberation Bundle and Strategies for Implementation in Pediatrics

2020

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Purpose of Review We briefly review post-intensive care syndrome (PICS) and the morbidities associated with critical illness that led to the intensive care unit (ICU) liberation movement. We review each element of the ICU liberation bundle, including pediatric support data, as well as tips and strategies for implementation in a pediatric ICU (PICU) setting. Recent Findings Numerous studies have found children have cognitive, physical, and psychiatric deficits after a PICU stay. The effects of the full ICU liberation bundle in children have not been published, but in adults, bundle implementation (even partial) resulted in significant improvement in survival, mechanical ventilation use, coma, delirium, restraint-free care, ICU readmissions, and post-ICU discharge disposition. Summary Although initially described in adults, children also suffer from PICS. The ICU liberation bundle is feasible in children and may ameliorate the effects of a PICU stay. Further studies are needed to characterize the benefits of the ICU liberation bundle in children.

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Section: Challenges To Bundle Implementationmentioning

confidence: 99%

The ICU Liberation Bundle and Strategies for Implementation in Pediatrics

2020

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“…The delivery of elements of the bundle to patients with COVID-19 infections was lower than that shown in nationwide and international prevalence surveys conducted before the pandemic (Supplemental Table 10) [5,28]. The ABCDEF bundle is a strong evidence-based approach to ICU care that prevents ICU patients from developing physical, cognitive, and mental disabilities, termed the post-intensive care syndrome (PICS) [29], which has long lasting effects even after intensive care and hospital discharge. Many studies have suggested that each element of the bundle has its own role to prevent PICS [1,5,6,8] and synchronized implementation would provide further bene ts [30].…”

Section: Discussionmentioning

confidence: 99%

ABCDEF Bundle and Supportive ICU Care Practices for patients with COVID-19 infection: An international point prevalence study ~The ISIIC Study~

Liu

Nakamura²,

Katsukawa³

et al. 2020

Preprint

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BackgroundAlthough the number of patients with COVID-19 infection is increasing and concerns for their long-term disabilities are increasing, there is a lack of data about the delivery of the ABCDEF-bundle and supportive care in Intensive Care Units (ICUs). The aim of this study is to investigate the implementation of the ABCDEF-bundle and supportive care provided to patients with COVID-19 infections in ICUs. MethodsThis was a world-wide two-day point prevalence study, on June 3 and July 1, 2020. A total of 212 ICUs in 38 countries (166 ICUs on Day 1 and 212 on Day 2) participated. Clinicians in each participating ICU completed web-based online surveys. The implementation rate for elements of the ABCDEF-bundle, other supportive ICU care measures and implementation associated structures were investigated.RESULTSData for 262 patients was collected during the two-day study. Of patients included, 124 (47.3%) underwent mechanical ventilation (MV) and 12 (4.6%) patients were treated with extracorporeal membrane oxygenation (ECMO). The proportion of patients with implementation of each element was: Element A (regular pain assessment) 45%; B (both spontaneous awakening and breathing trials) 28%; C (regular sedation assessment) 52%; D (regular delirium assessment) 38%; E (early mobility and exercise) 47%; and F (family engagement and empowerment) 16%. The implementation of element E for patients on MV was 16% and ECMO was 17%. Supportive care, such as providing protein throughout the ICU stay (under 1.2g/kg for more than 50% of the patients) and introduction of an ICU diary (25%) was inadequate. A higher implementation rate of elements A and D were recognized in ICUs with specific protocols for ICU care and lower numbers of ICU beds exclusively for patients with COVID-19 infection. Element E was implemented at a higher rate in ICUs with more ICU beds for patients with COVID-19 infection.CONCLUSIONSThis worldwide two-day point prevalence study found low implementation of the ABCDEF-bundle. Specific protocols and the number of ICU beds reserved for patients with COVID-19 infections might be key factors to deliver appropriate supportive care.Trial registration: UMIN, UMIN000040405. Registered 14 May 2020, https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000046103

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“…169 The majority are related to the clinician implementing the bundle, in particular lack of knowledge about its benefits, reluctance to follow guidelines, preference for autonomy, perceived increased workload, 170 and lack of confidence in the bundle's efficacy. [169][170][171] Finally, there are barriers related to the structure of the ICU, including culture and organization, teamwork, physical environment, lack of resources, and inadequate management/leadership. 169,171,172 Practical Considerations for the Treatment of Delirium At the individual level, for the clinician at the bedside, the management of delirium can be difficult.…”

Section: Implementation Challenges and Difficultiesmentioning

confidence: 99%

“…[169][170][171] Finally, there are barriers related to the structure of the ICU, including culture and organization, teamwork, physical environment, lack of resources, and inadequate management/leadership. 169,171,172 Practical Considerations for the Treatment of Delirium At the individual level, for the clinician at the bedside, the management of delirium can be difficult. The physician must understand delirium as a form of acute organ failure, in this instance, a form of acute brain failure.…”

Section: Implementation Challenges and Difficultiesmentioning

confidence: 99%

Prevention and Management of Delirium in the Intensive Care Unit

Mart

Roberson

Salas

et al. 2020

Semin Respir Crit Care Med

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Delirium is a debilitating form of brain dysfunction frequently encountered in the intensive care unit (ICU). It is associated with increased morbidity and mortality, longer lengths of stay, higher hospital costs, and cognitive impairment that persists long after hospital discharge. Predisposing factors include smoking, hypertension, cardiac disease, sepsis, and premorbid dementia. Precipitating factors include respiratory failure and shock, metabolic disturbances, prolonged mechanical ventilation, pain, immobility, and sedatives and adverse environmental conditions impairing vision, hearing, and sleep. Historically, antipsychotic medications were the mainstay of delirium treatment in the critically ill. Based on more recent literature, the current Society of Critical Care Medicine (SCCM) guidelines suggest against routine use of antipsychotics for delirium in critically ill adults. Other pharmacologic interventions (e.g., dexmedetomidine) are under investigation and their impact is not yet clear. Nonpharmacologic interventions thus remain the cornerstone of delirium management. This approach is summarized in the ABCDEF bundle (Assess, prevent, and manage pain; Both SAT and SBT; Choice of analgesia and sedation; Delirium: assess, prevent, and manage; Early mobility and exercise; Family engagement and empowerment). The implementation of this bundle reduces the odds of developing delirium and the chances of needing mechanical ventilation, yet there are challenges to its implementation. There is an urgent need for ongoing studies to more effectively mitigate risk factors and to better understand the pathobiology underlying ICU delirium so as to identify additional potential treatments. Further refinements of therapeutic options, from drugs to rehabilitation, are current areas ripe for study to improve the short- and long-term outcomes of critically ill patients with delirium.

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Common Challenges to Effective ABCDEF Bundle Implementation: The ICU Liberation Campaign Experience

Cited by 60 publications

References 87 publications

The ICU Liberation Bundle and Strategies for Implementation in Pediatrics

The ICU Liberation Bundle and Strategies for Implementation in Pediatrics

ABCDEF Bundle and Supportive ICU Care Practices for patients with COVID-19 infection: An international point prevalence study ~The ISIIC Study~

Prevention and Management of Delirium in the Intensive Care Unit

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