Effects of a National Quality Improvement Collaborative on ABCDEF Bundle Implementation

Background The ABCDEF bundle (Assess, prevent, and manage pain and Delirium; Both spontaneous awakening and breathing trials; Choice of analgesia/sedation; Early mobility; and Family engagement) improves intensive care unit outcomes, but adoption into practice is poor. Objective To assess the effect of quality improvement collaborative participation on ABCDEF bundle performance. Methods This interrupted time series analysis included 20 months of bundle performance data from 15 226 adults admitted to 68 US intensive care units. Segmented regression models were used to quantify complete and individual bundle element performance changes over time and compare performance patterns before (6 months) and after (14 months) collaborative initiation. Results Complete bundle performance rates were very low at baseline (<4%) but increased to 12% by the end. Complete bundle performance increased by 2 percentage points (SE, 0.9; P = .06) immediately after collaborative initiation. Each subsequent month was associated with an increase of 0.6 percentage points (SE, 0.2; P = .04). Performance rates increased significantly immediately after initiation for pain assessment (7.6% [SE, 2.0%], P = .002), sedation assessment (9.1% [SE, 3.7%], P = .02), and family engagement (7.8% [SE, 3%], P = .02) and then increased monthly at the same speed as the trend in the baseline period. Performance rates were lowest for spontaneous awakening/breathing trials and early mobility. Conclusions Quality improvement collaborative participation resulted in clinically meaningful, but small and variable, improvements in bundle performance. Opportunities remain to improve adoption of sedation, mechanical ventilation, and early mobility practices.

Implementation of the ABCDEF Bundle for Critically Ill ICU Patients During the COVID-19 Pandemic: A Multi-National 1-Day Point Prevalence Study

Background: Data regarding delivery of evidence-based care to critically ill patients in Intensive Care Units (ICU) during the COVID-19 pandemic is crucial but lacking. This study aimed to evaluate the implementation rate of the ABCDEF bundle, which is a collection of six evidence-based ICU care initiatives which are strongly recommended to be incorporated into clinical practice, and ICU diaries for patients with and without COVID-19 infections in ICUs, and to analyze the impact of COVID-19 on implementation of each element of the bundle and independent associated factors.Methods: A world-wide 1-day point prevalence study investigated the delivery of the ABCDEF bundle and ICU diary to patients without or with COVID-19 infections on 27 January 2021 via an online questionnaire. Multivariable logistic regression analysis with adjustment for patient demographics evaluated the impact of COVID-19 and identified factors in ICU administrative structures and policies independently associated with delivery.Results: From 54 countries and 135 ICUs, 1,229 patients were eligible, and 607 (49%) had COVID-19 infections. Implementation rates were: entire bundle (without COVID-19: 0% and with COVID-19: 1%), Element A (regular pain assessment: 64 and 55%), Element B (both spontaneous awakening and breathing trials: 17 and 10%), Element C (regular sedation assessment: 45 and 61%), Element D (regular delirium assessment: 39 and 35%), Element E (exercise: 22 and 25%), Element F (family engagement/empowerment: 16 and 30%), and ICU diary (17 and 21%). The presence of COVID-19 was not associated with failure to implement individual elements. Independently associated factors for each element in common between the two groups included presence of a specific written protocol, application of a target/goal, and tele-ICU management. A lower income status country and a 3:1 nurse-patient ratio were significantly associated with non-implementation of elements A, C, and D, while a lower income status country was also associated with implementation of element F.Conclusions: Regardless of COVID-19 infection status, implementation rates for the ABCDEF bundle, for each element individually and an ICU diary were extremely low for patients without and with COVID-19 infections during the pandemic. Strategies to facilitate implementation of and adherence to the complete ABCDEF bundle should be optimized and addressed based on unit-specific barriers and facilitators.

Post-Intensive Care Syndrome and Its New Challenges in Coronavirus Disease 2019 (COVID-19) Pandemic: A Review of Recent Advances and Perspectives

Intensive care unit survivors experience prolonged physical impairments, cognitive impairments, and mental health problems, commonly referred to as post-intensive care syndrome (PICS). Previous studies reported the prevalence, assessment, and prevention of PICS, including the ABCDEF bundle approach. Although the management of PICS has been advanced, the outbreak of coronavirus disease 2019 (COVID-19) posed an additional challenge to PICS. The prevalence of PICS after COVID-19 extensively varied with 28–87% of cases pertaining to physical impairments, 20–57% pertaining to cognitive impairments, and 6–60% pertaining to mental health problems after 1–6 months after discharge. Each component of the ABCDEF bundle is not sufficiently provided from 16% to 52% owing to the highly transmissible nature of the virus. However, new data are emerging about analgesia, sedation, delirium care, nursing care, early mobilization, nutrition, and family support. In this review, we summarize the recent data on PICS and its new challenge in PICS after COVID-19 infection.

Effectiveness of the ABCDEF bundle on delirium, functional outcomes and quality of life in intensive care patients: a study protocol for a randomised controlled trial with embedded process evaluation

IntroductionHospital mortality for critically ill patients has decreased significantly throughout the developed world over the past two decades, attributable to improvements in the quality of intensive care, advances in critical care medicine and technologies that provide long-term multiorgan support. However, the long-term outcomes of intensive care unit (ICU) survivors is emerging as a real issue. Cognitive and physical impairments suffered by ICU survivors are common including profound weakness, pain and delirium which are inextricably linked. This study aims to determine the effectiveness of the Assess, prevent and manage pain; Both spontaneous awakening and spontaneous breathing trials; Choice of sedation and analgesia; Delirium: assess, prevent and manage; Early mobility and exercise; Family engagement and empowerment (ABCDEF) bundle in reducing ICU-related short-term and long-term consequences of critical illness through a randomised controlled trial (RCT).Methods and analysisThe study will be a single-centre, prospective RCT. A total of 150 participants will be recruited and randomised to either receive the ABCDEF bundle protocol or non-protocolised standard care for the duration of the participant’s admission in the ICU. The primary outcome is delirium status measured using the Confusion Assessment Measure for ICU (CAM-ICU). Secondary outcomes include physical function measured by the Functional Independence Measure and quality of life measured by the European Quality of Life five dimensions, five-level questionnaire. A mixed-method process evaluation will contribute to understanding the experience of health teams who implement the ABCDEF bundle into practice.Ethics and disseminationEthics approval was provided by the Metro South Health Human Research Ethics Committee (HREC) (EC00167) and the Griffith University’s HREC prior to study commencement.Study results will be disseminated by presentations at conferences and via publications to peer-review journals.Trial registration numberACTRN12620000736943; Pre-results.

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.