Implementation of the ABCDEF Bundle in an Academic Medical Center

Abstract

• Objective: To describe the highlights of our medical center’s implementation of the Society of Critical Care Medicine’s ABCDEF bundle in 3 medical intensive care units (ICUs).
• Methods: After a review of our current clinical practices and written clinical guidelines, we evaluated deficiencies in clinical care and employed a variety of educational and clinical change interventions for each element of the bundle. We utilized an interdisciplinary team approach to facilitate the change process.
• Results: As a result of our efforts, improvement in the accuracy of assessments of pain, agitation, and delir-ium across all clinical disciplines and improved adherence to clinical practice guidelines, protocols, and instruments for all bundle elements was seen. These changes have been sustained following completion of the data collection phase of the project.
• Conclusion: ICU care is a team effort. As a result of participation in this initiative, there has been an increased awareness of the bundle elements, improved collaboration among team members, and increased patient and family communication.

Key words: intensive care; delirium; sedation; mobility.

Admission to the intensive care unit (ICU) is a stressful and challenging time for patients and their families. In addition, significant negative sequelae following an ICU stay have been reported in the literature, including such post-ICU complications as post-traumatic stress disorder [1–9], depression [10,11], ICU-acquired weakness [12–19], and post-intensive care syndrome [20–23]. Pain, anxiety, and delirium all contribute to patient distress and agitation, and the prevention or treatment of pain, anxiety, and delirium in the ICU is an important goal. The Society of Critical Care Medicine (SCCM) developed the ABCDEF bundle (Table) to facilitate implementation of their 2013 clinical practice guidelines for the management of pain, agitation, and delirium (PAD) [24]. The bundle emphasizes an integrated approach to assessing, treating and preventing significant pain, over or undersedation, and delirium in critically ill patients.

In 2015, SCCM began the ICU Liberation Collaborative, a clinical care collaborative designed to implement the ABCDEF bundle through team-based care at hospitals and health systems across the country. The Liberation Collaborative’s intent was to “liberate” patients from iatrogenic aspects of care [25]. Our medical center participated in the collaborative. In this article, we describe the highlights of our medical center’s implementation of the ABCDEF bundle in 3 medical ICUs.

Settings

The Ohio State University Wexner Medical Center is a 1000+–bed academic medical center located in Columbus, Ohio, containing more than 180 ICU beds. These ICU beds provide care to patients with medical, surgical, burn, trauma, oncology, and transplantation needs. The care of the critically ill patient is central to the organization’s mission “to improve people’s lives through innovation in research, education and patient care.”

The medical center has 3 medical ICUs (MICUs) in 3 different physical locations, but they have the same nursing and physician leadership. Two of the MICU units have an interdisciplinary team that includes physicians (attending and fellow) along with advanced practice nurses as patient care providers. One of the MICUs provides the traditional medical model and does not utilize advanced practice nurses as providers. The guidelines and standards of care for all health care team members are standardized across the 3 MICU locations with one quality committee to provide oversight.

At the start of our colloborative participation, all of the ABCDEF bundle elements were protocolized in these ICUs. However, there was a lack of knowledge of the content of the bundle elements and corresponding guidelines among all members of our interdisciplinary teams, and our written protocols and guidelines supporting many of the bundle elements had inconsistent application across the 3 clinical settings.

We convened an ABCDEF bundle/ICU liberation team consisting of an interdisciplinary group of clinicians. The team leader was a critical care clinical nurse specialist. The project required outcome and demographic data collection for all patients in the collaborative as well as concurrent (daily) data collection on each bundle element. The clinical pharmacists who work in the MICUs and are part of daily interdisciplinary rounds collected the daily bundle element data while the patient demographic and outcome data were collected by the clinical nurse specialist, nurse practitioner, and clinical quality manager. Oversight and accountability for the ABCDEF bundle/ICU liberation project was provided by an interdisciplinary critical care quality committee. Our ABCDEF bundle/ICU liberation team met weekly to discuss progress of the initiative and provided monthly updates to the larger quality committee.

Impacting the Bundle—Nursing Assessments

The PAD guidelines recommend the routine assessment of pain, agitation, and delirium in ICU patients. For pain, they recommend the use of patient self-report or the use of a behavioral pain scale as the most valid and reliable method for completing this assessment [24]. Our medical center had chosen to use the Critical Care Pain Observation Tool (CPOT), a valid and reliable pain scale, for assessment of pain in patients who are unable to communicate [26], which had been in use in the clinical setting for over a year when this project began. For agitation, the PAD guidelines recommended assessment of the adequacy and depth of sedation using the Richmond Agitation Sedation Scale (RASS) or Sedation Agitation Scale (SAS) [24] for all ICU patients. Our medical center has chosen to use the RASS as our delirium assessment. The RASS had been in use in the clinical setting for approximately 10 years when this project started. For delirium assessment, the Confusion Assessment Method for ICU (CAM-ICU) [27] or the Intensive Care Delirium Screening Checklist (ICDSC) [28] is recommended. Our medical center used the CAM-ICU, which had been in place for approximately 10 years prior to the start of this project. Even though the assessment tools were in place in our MICU unit and hospital-based policies and guidelines, the accuracy of the assessments for PAD was questioned by many clinicians.

To improve the accuracy of our nursing assessments for PAD, a group of clinical nurse specialists and nursing educators developed an education and competency program for all critical care nursing staff. This education program focused on the PAD guidelines and our medical center’s chosen assessment tools. Education included in-person continuing education lectures, online modules, demonstrations, and practice in the clinical setting. After several months of education and practice, all staff registered nurses (RNs) had to demonstrate PAD assessment competency on a live person. We used standardized patients who followed written scenarios for all of the testing. The RN was given 1 of 8 scenarios and was charged with completing a PAD assessment on the standardized patient. RNs who did not pass had to review the education materials and re-test at a later date. More than 600 RNs completed the PAD competency. After completion of the PAD competency, the clinical nurse specialists observed clinical practice and audited nursing documentation. The accuracy of assessments for PAD had increased. Anecdotally, many our critical care clinicians acknowledged that they had increased confidence in the accuracy of the PAD assessments. There was increased agreement between the results of the assessments performed by all members of the interdisciplinary team.