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

DOI Web Site 7 Citations
  • Brenda T. Pun
    Department of Medicine, Pulmonary and Critical Care, Critical Illness, Brain dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN.
  • Michele C. Balas
    The Ohio State University, College of Nursing, Columbus, OH.
  • Mary Ann Barnes-Daly
    Sutter Health, Sacramento, CA.
  • Jennifer L. Thompson
    Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN.
  • J. Matthew Aldrich
    Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA.
  • Juliana Barr
    Stanford University School of Medicine, Stanford, CA.
  • Diane Byrum
    Innovative Solutions for Healthcare Education, LLC, Charlotte, NC.
  • Shannon S. Carson
    University of North Carolina School of Medicine, Chapel Hill, NC.
  • John W. Devlin
    School of Pharmacy, Northeastern University and Division of Pulmonary and Critical Care Medicine, Tufts Medical Center, Boston, MA.
  • Heidi J. Engel
    Department of Rehabilitative Services, University of California, San Francisco, San Francisco, CA.
  • Cheryl L. Esbrook
    University of Chicago Medicine, Chicago, IL.
  • Ken D. Hargett
    Houston Methodist Hospital, Houston, TX.
  • Lori Harmon
    Society of Critical Care Medicine, Mount Prospect, IL.
  • Christina Hielsberg
    Society of Critical Care Medicine, Mount Prospect, IL.
  • James C. Jackson
    Department of Medicine, Pulmonary and Critical Care, Critical Illness, Brain dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN.
  • Tamra L. Kelly
    Sutter Health, Sacramento, CA.
  • Vishakha Kumar
    Society of Critical Care Medicine, Mount Prospect, IL.
  • Lawson Millner
    Novant Health, Forsyth Medical Center, Winston-Salem, NC.
  • Alexandra Morse
    Sutter Health, Sacramento, CA.
  • Christiane S. Perme
    Houston Methodist Hospital, Houston, TX.
  • Patricia J. Posa
    Saint Joseph Mercy Health System, Ann Arbor, MI.
  • Kathleen A. Puntillo
    Department of Physiological Nursing, School of Nursing, University of California, San Francisco, San Francisco, CA.
  • William D. Schweickert
    Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
  • Joanna L. Stollings
    Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN.
  • Alai Tan
    The Ohio State University, College of Nursing, Columbus, OH.
  • Lucy D’Agostino McGowan
    The Department of Biostatistics, Johns Hopkins University, Baltimore, MD.
  • E. Wesley Ely
    Department of Medicine, Pulmonary and Critical Care, Critical Illness, Brain dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN.

Description

<jats:sec> <jats:title>Objective:</jats:title> <jats:p>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.</jats:p> </jats:sec> <jats:sec> <jats:title>Design:</jats:title> <jats:p>Prospective, multicenter, cohort study from a national quality improvement collaborative.</jats:p> </jats:sec> <jats:sec> <jats:title>Setting:</jats:title> <jats:p>68 academic, community, and federal ICUs collected data during a 20-month period.</jats:p> </jats:sec> <jats:sec> <jats:title>Patients:</jats:title> <jats:p>15,226 adults with at least one ICU day.</jats:p> </jats:sec> <jats:sec> <jats:title>Interventions:</jats:title> <jats:p>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 and 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.</jats:p> </jats:sec> <jats:sec> <jats:title>Measurements and Results:</jats:title> <jats:p>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 <jats:italic toggle="yes">p</jats:italic> < 0.002). Significant pain was more frequently reported as bundle performance proportionally increased (<jats:italic toggle="yes">p</jats:italic> = 0.0001).</jats:p> </jats:sec> <jats:sec> <jats:title>Conclusions:</jats:title> <jats:p>ABCDEF bundle performance showed significant and clinically meaningful improvements in outcomes including survival, mechanical ventilation use, coma, delirium, restraint-free care, ICU readmissions, and post-ICU discharge disposition.</jats:p> </jats:sec>

Journal

  • Critical Care Medicine

    Critical Care Medicine 47 (1), 3-14, 2019-01

    Ovid Technologies (Wolters Kluwer Health)

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