Improving Health Care for Critically Ill Patients Using an Evidence‐Based Collaborative Approach to ABCDEF Bundle Dissemination and Implementation

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

doi:10.1111/wvn.12290

Cited by 64 publications

(60 citation statements)

References 38 publications

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“…At the heart of this safety bundle lies the brain, the most vital organ of the human body, and it has been shown now in over 25,000 patients [37,39,82,83] that higher compliance yields better survival, less delirium and coma, shorter lengths of stay, less ICU bounce-back, and lower cost of care. Implementation at the bedside of excellent delirium prevention and management should be a priority during the COVID-19 pandemic [84,85].…”

Section: Discussionmentioning

confidence: 99%

COVID-19: ICU delirium management during SARS-CoV-2 pandemic

et al. 2020

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The novel coronavirus, SARS-CoV-2-causing Coronavirus Disease 19 , emerged as a public health threat in December 2019 and was declared a pandemic by the World Health Organization in March 2020. Delirium, a dangerous untoward prognostic development, serves as a barometer of systemic injury in critical illness. The early reports of 25% encephalopathy from China are likely a gross underestimation, which we know occurs whenever delirium is not monitored with a valid tool. Indeed, patients with COVID-19 are at accelerated risk for delirium due to at least seven factors including (1) direct central nervous system (CNS) invasion, (2) induction of CNS inflammatory mediators, (3) secondary effect of other organ system failure, (4) effect of sedative strategies, (5) prolonged mechanical ventilation time, (6) immobilization, and (7) other needed but unfortunate environmental factors including social isolation and quarantine without family. Given early insights into the pathobiology of the virus, as well as the emerging interventions utilized to treat the critically ill patients, delirium prevention and management will prove exceedingly challenging, especially in the intensive care unit (ICU). The main focus during the COVID-19 pandemic lies within organizational issues, i.e., lack of ventilators, shortage of personal protection equipment, resource allocation, prioritization of limited mechanical ventilation options, and end-of-life care. However, the standard of care for ICU patients, including delirium management, must remain the highest quality possible with an eye towards long-term survival and minimization of issues related to post-intensive care syndrome (PICS). This article discusses how ICU professionals (e.g., physicians, nurses, physiotherapists, pharmacologists) can use our knowledge and resources to limit the burden of delirium on patients by reducing modifiable risk factors despite the imposed heavy workload and difficult clinical challenges posed by the pandemic.

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Section: Discussionmentioning

confidence: 99%

COVID-19: ICU delirium management during SARS-CoV-2 pandemic

et al. 2020

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“…Additionally, data abstraction for these bundle elements is cumbersome because individual elements of the ABCDEF bundle are often separate and disconnected in current designs of electronic medical record (EMR) systems (e.g., EPIC and CERNER) which often have siloed screens and standard views that vary significantly depending on the user and institution. User-friendly EMR platforms that are easily adaptable would better support ongoing QI and research in this area (26, 34, 56−58). Additionally, data collected by multiple team members should be seamlessly displayed on integrated EMR dashboards accessible by all team members so that patients’ ABCDEF bundle progress can be monitored in a collaborative way (e.g., one-stop dashboard screen access for all bundle elements).…”

Section: Discussionmentioning

confidence: 99%

“…A description of the ICU Liberation Collaborative’s history, requirements for participation, and data collection procedures is provided in Supplemental Digital Content (SDC) Methods 1 and other publications (14, 34). Guided by the Consolidated Framework for Implementation Research (35) and based on published trials (14) and recommendations (2, 3, 36), a panel of 23 interprofessional ICU clinicians with expertise in QI and the bundle domains reached consensus on how the current version of the ABCDEF bundle should be operationally defined and measured in practice ( SDC Table 1 ) .…”

Section: Methodsmentioning

confidence: 99%

“…This investigation provides clinical outcome results from the Society of Critical Care Medicine (SCCM) ICU Liberation Collaborative that was funded by the Gordon and Betty Moore Foundation. The collaborative included more than 15,000 patients from 68 community, academic, federal, and private ICUs (34). The quality improvement (QI) results of the ICU Liberation Project (i.e., whether collaborative participation resulted in increased adherence to the bundle and its individual elements over time) will be reported in a separate article.…”

Section: Introductionmentioning

confidence: 99%

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Caring for Critically Ill Patients with the ABCDEF Bundle: Results of the ICU Liberation Collaborative in Over 15,000 Adults

Pun

Balas

Barnes‐Daly

et al. 2019

Critical Care Medicine

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717

326

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Objective: Decades-old, common ICU practices including deep sedation, immobilization, and limited family access are being challenged. We endeavoured to evaluate the relationship between ABCDEF bundle performance and patient-centered outcomes in critical care. Design: Prospective, multicenter, cohort study from a national quality improvement collaborative. Setting: 68 academic, community, and federal ICUs collected data during a 20-month period. Patients: 15,226 adults with at least one ICU day. Interventions: We defined ABCDEF bundle performance (our main exposure) in two ways: 1) complete performance (patient received every eligible bundle element on any given day) and 2) proportional performance (percentage of eligible bundle elements performed on any given day). We explored the association between complete and proportional ABCDEF bundle performance and three sets of outcomes: patient-related (mortality, ICU hospital discharge), symptom-related (mechanical ventilation, coma, delirium, pain, restraint use), and system-related (ICU readmission, discharge destination). All models were adjusted for a minimum of 18 a priori determined potential confounders. Measurements and Results: Complete ABCDEF bundle performance was associated with lower likelihood of seven outcomes: hospital death within 7 days (adjusted hazard ratio, 0.32; CI, 0.17–0.62), next-day mechanical ventilation (adjusted odds ratio [AOR], 0.28; CI, 0.22–0.36), coma (AOR, 0.35; CI, 0.22–0.56), delirium (AOR, 0.60; CI, 0.49–0.72), physical restraint use (AOR, 0.37; CI, 0.30–0.46), ICU readmission (AOR, 0.54; CI, 0.37–0.79), and discharge to a facility other than home (AOR, 0.64; CI, 0.51–0.80). There was a consistent dose-response relationship between higher proportional bundle performance and improvements in each of the above-mentioned clinical outcomes (all p < 0.002). Significant pain was more frequently reported as bundle performance proportionally increased (p = 0.0001). Conclusions: ABCDEF bundle performance showed significant and clinically meaningful improvements in outcomes including survival, mechanical ventilation use, coma and delirium, restraint-free care, ICU readmissions, and post-ICU discharge disposition.

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“…The ICU Liberation guidelines and the set of ABCDEF measures are vital resources to assess, treat and prevent pain, agitation and delirium. (14,15) The initiative also focuses on strategies of early mobilization, that can help to reduce the risks of long-term consequences of ICU admissions.…”

Section: ❚ Discussionmentioning

confidence: 99%

Practices related to assessment of sedation, analgesia and delirium among critical care pediatricians in Brazil

Colleti

Araújo

Andrade

et al. 2020

Einstein (São Paulo)

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Objective: To understand the use of tools, protocols and comfort measures related to sedation/ analgesia, and to screen the occurrence of delirium in pediatric intensive care units. Methods: A survey with 14 questions was distributed by e-mail to Brazilian critical care pediatricians. Eight questions addressed physician and hospital demographics, and six inquired practices to assess sedation, analgesia, and delirium in pediatric intensive care units. Results: Of 373 questionnaires sent, 61 were answered (16.3%). The majority of physicians were practicing in the Southeast region (57.2%). Of these, 46.5% worked at public hospitals, 28.6% of which under direct state administration. Of respondents, 57.1% used formal protocols for sedation and analgesia, and the Ramsay scale was the most frequently employed (52.5%). Delirium screening scores were not used by 48.2% of physicians. The Cornell Assessment of Pediatric Delirium was the score most often used (23.2%). The majority (85.7%) of physicians did not practice daily sedation interruption, and only 23.2% used non-pharmacological measures for patient comfort frequently, with varied participation of parents in the process. Conclusion: This study highlights the heterogeneity of practices for assessment of sedation/analgesia and lack of detection of delirium among critical care pediatricians in Brazil.

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Improving Health Care for Critically Ill Patients Using an Evidence‐Based Collaborative Approach to ABCDEF Bundle Dissemination and Implementation

Abstract: Hospitals and health systems can use the Collaborative structure, strategies, and tools described in this paper to help successfully implement the ABCDEF bundle in their ICUs.

Cited by 64 publications

References 38 publications

COVID-19: ICU delirium management during SARS-CoV-2 pandemic

COVID-19: ICU delirium management during SARS-CoV-2 pandemic

Caring for Critically Ill Patients with the ABCDEF Bundle: Results of the ICU Liberation Collaborative in Over 15,000 Adults

Practices related to assessment of sedation, analgesia and delirium among critical care pediatricians in Brazil

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