ABCDEF Bundle Implementation: The influence of access to bundle-enhancing supplies and equipment
Importance: The ABCDEF bundle is a guideline-recommended framework for implementing evidence-based practices in the Intensive Care Unit (ICU), but it is underutilized across the world. Objective: Describe the physical environment factors (i.e., availability, accessibility) of bundle-enhancing items in units implementing the bundle and the influence of physical environment on bundle adherence. Design, Setting, and Participants: This multicenter, exploratory, cross-sectional study used data from two ICU-based randomized controlled trials (RCTs) (NCT01211522 and NCT01739933) that measured daily bundle adherence. The study included 10 medical and surgical ICUs in 6 academic medical centers in the continental United States. Adults with qualifying respiratory failure and/or septic shock (e.g., mechanical ventilation, vasopressor use) were included in the RCTs. Unit- and patient-level data collection occurred between 2011 and 2016. We conducted hierarchical logistic regression models using Frequentist and Bayesian frameworks. Exposure: The ABCDE bundle (Awakening and Breathing trial Coordination, Delirium assessment/management, Early mobility) was recommended standard of care for RCT patients and adherence tracked daily. Main Outcome(s) and Measure(s): The primary outcome was adherence to the full bundle and the early mobility bundle component as identified from daily adherence documentation (n=751 patient observations). Unit-level measures included minimum and maximum distances to 25 bundle-enhancing items and the relationship to bundle adherence. Results: Daily ventilator status was the only variable to suggest an influence on bundle adherence in all modeling approaches. In all cases, mechanical ventilation was associated with decreased bundle adherence. Some of the models suggested the following variables were also influential: age (older associated with decreased adherence), unit size (larger associated with decreased adherence), and a standard walker (presence associated with increased adherence). Conclusions and Relevance: Both unit- and patient-level barriers influenced full bundle and early mobility implementation. There is potential benefit of physical proximity to essential items for ABCDEF bundle and early mobility adherence. Future studies with larger sample sizes should explore how equipment location and availability influences practice.