Speakers
Eduard Vasilevskis, MD, MPH
Professor of Medicine
Department of Medicine, Division of Hospital Medicine
University of Wisconsin-Madison
Michele C. Balas PhD, RN, CCRN-K, FCCM, FAAN
Associate Dean of Research
Dorothy Hodges Olson Distinguished Professor of Nursing
University of Nebraska Medical Center College of Nursing
Keywords
Intensive Care; ICU; Implementation; Evidence-Based Practices
Key Points
- With recent increases in survivorship for Intensive Care Unit (ICU) patients has come the rise of Post-ICU Syndrome, or PICS. PICS is characterized by cognitive and physical impairment; financial toxicity; and family impacts. Some of the factors associated with PICS are modifiable: Sedation use, for example, immobility, and mechanical ventilation.
- A set of evidence-based best practices based on these modifiable factors are encapsulated in the ABCDEF Bundle: Assess, prevent, and manage pain; Both spontaneous awakening trials (SATs) and spontaneous breathing trials (SBTs); Choice of analgesia and sedation; Delirium: assess, prevent, and manage; Early exercise and mobility; and Family engagement.
- In a study of 68 ICUs, patients treated with all elements of the ABCDEF bundle in a given day had better outcomes. The next day, they were 70% less likely to be on a mechanical ventilator; 65% less likely to be in a coma; and 40% less likely to be delirious. Though there wasn’t a significant impact on pain, the likelihood of being discharged from the hospital increased by 20%.
- We have a safe and efficacious set of evidence-based practices that people can deliver in the ICU. However, many of them are not being delivered to critically ill patients. And they’re not being delivered due to numerous implementation challenges clinicians experience in everyday care.
- The Behavioral Economic and Staffing Strategies to Increase Adoption of the ABCDEF Bundle in the Intensive Care Unit (BEST-ICU) study aims to evaluate 2 strategies grounded in behavioral economic and implementation science theory to increase adoption of the ABCDEF bundle. The strategies target a variety of ICU team members and known behavioral determinants of ABCDEF bundle performance.
- BEST-ICU is ongoing. The hybrid type III effectiveness-implementation pragmatic trial will take place in 3 hospitals and 12 ICUs across 33 months. The study team will monitor fidelity through real-time monthly tracking of audit and feedback information and through direct observation by Registered Nurse (RN) Implementation Facilitators.
- Over 3,000 work intensity surveys have already been completed, split between RNs and non-nurses. Given the intensive nature of these surveys and the dearth of studies investigating work intensity in the ICU, this alone will be a notable contribution to the literature.
- The research team outlined some of their sticking points around dashboard development and data acquisition/sharing, as well as how they’ve addressed these challenges. Solutions included the standardization of definitions for bundle process elements and engagement of clinical, operational, and legal leadership from the University & Health system.
Discussion Themes
Patient-reported pain was the only outcome that didn’t improve following full implementation of ABCDEF bundle. Dr. Balas noted that patients who aren’t in a coma anymore can then report pain. Dr. Vasilevskis pointed out that the same goes for delirium, which is far preferable to coma from a mortality perspective.
Dr. Balas suggested that a patient who is more cognitively engaged and able to report pain is actually in a better spot, as it enables medical staff to treat them.