Implementation of the Evidence-Based ABCDEF Bundle in a Surgical Intensive Care Unit: Process and Outcomes

Background: Pain, agitation and delirium are major problems that critically ill patients, their families and clinicians face in the intensive care units (ICU). These problems play a major role in the development of post-intensive care syndrome (PICS) - which are physical, cognitive or mental impairments that can occur to patients and families after ICU discharge. The Society of Critical Care Medicine’s (SCCM) clinical practice guidelines for the management of pain, agitation and delirium (PAD) in adult patients in the ICUs provides an extensive set of evidence-based recommendations addressing these three major problems. A quality improvement initiative called ICU Liberation Collaborative is designed by the SCCM to facilitate the implementation of PAD guidelines using the evidence-based ABCDEF bundle. These bundle elements consist of A) assessment, prevention and treatment of pain; B) Both spontaneous breathing and awakening trials; C) Choice of analgesia and sedation; D) Delirium assessment, prevention and treatment; E) Early mobility and Exercise; F) Family Engagement and Empowerment. Improvements can be made in pain management, delirium prevention, and overall patient outcomes by incorporating each ABCDEF bundle elements into daily ICU workflow and practice. Our cardiothoracic/surgical ICU at a large academic center was one of the 77 hospital units involved in this national quality improvement initiative.

Purpose: 1. Describe the ABCDEF bundle implementation process and outcomes using an interprofessional team approach in a surgical ICU at large academic medical center. 2. Compare the unit bundle compliance to all sites and peer regions involved in the quality improvement initiative.

Methods: A unit-based interprofessional team (IPT) came together to assess, plan, implement, and evaluate the implementation of the ABCDEF bundle in a cardiothoracic/surgical ICU at a large academic medical center. Team consisted of an intensivist (project leader), unit assistant director (team leader), the unit director, four staff nurses, a respiratory therapist, and physical therapist. Team members received training in the clinical and IPT aspects of the project before its implementation and data collection. Retrospective and prospective data were collected before and after the implementation of the project. Retrospective data served as a gap analysis and assisted team members in identifying areas of improvement in each of the bundle elements and designing effective evidence-based strategies to improve outcomes in the unit. The team regularly met and carefully designed the implementation of the bundle. The outcome measures were individual bundle element compliance out of all ICU days and staff perception of collaboration pre and post implementation of the initiative.

Outcomes: A total of 286 cases were reviewed (30 during retrospective period and 256 during the prospective period). Major practice changes related to bundle elements included introduction of 1) A validated pain assessment tool for non-verbal/ventilated patients; 2) A validated delirium (CAM-ICU) and sedation assessment (RASS) tools; 3) Safety screening tool for mobility; 4) Sedation/analgesia and delirium protocols. Compliance with the validated pain assessment tool was above 95% out of all ICU days. Compliance with the delirium assessment increased from 57% to above 85% and the compliance with validated sedation/agitation assessment tool increased from 0% to 90% after the implementation of the bundle. Compared to retrospective data, compliance with the patients passing an early exercise/mobility screening increased from 8% to 100%. In addition, the compliance with early mobility performance remained above 90%. Family member participation in daily clinical rounds and family engagement in the plan of care increased from 85% to 100%. After the implementation of the bundle, the use of benzodiazepines decreased by 75%. Our unit showed higher compliance of all bundle elements and specifically “E” element (early mobility/exercise) of the bundle in comparison to the other sites involved in the project. Post-survey showed higher mean scores in teamwork and collaboration.

Conclusion: Incorporating the ABCDEF bundle in our unit has improved teamwork and interprofessional communication and collaboration. Overall, the most significant changes made and sustained were adoption of validated pain assessment tool for non-verbal patients, validated delirium, sedation/agitation assessment tools, and mobility safety screening. The bundle elements are currently incorporated in the ICU daily goal sheets for use with every patient, every day.