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Contextual Issues Influencing Implementation and Outcomes Associated With an Integrated Approach to Managing Pain, Agitation, and Delirium in Adult ICUs

Carrothers, Kathleen M. MPH1; Barr, Juliana MD, FCCM2,3; Spurlock, Bruce MD1; Ridgely, M. Susan JD4; Damberg, Cheryl L. PhD4,5; Ely, E. Wesley MD, MPH6,7

doi: 10.1097/CCM.0b013e3182a2c2b1
Creating and Implementing the 2013 ICU Pain, Agitation, and Delirium Guidelines for Adult Icu Patients

Objective: This pilot study was designed to identify which contextual factors facilitate/hinder the implementation of the awakening, breathing, coordination, delirium, and early mobility (ABCDE) bundle for guidance in future studies.

Design: The sources of data for this study included document review, planned site visits (including interviews and observations), a brief online contextual factors survey, and self-reported process and outcome data.

Patients: All patients in the four participating SF Bay Area ICUs were eligible to be included in this pilot study.

Setting: This study took place in the four San Francisco Bay Area ICUs participating in the ICU Clinical Impact Interest Group, funded by the Gordon and Betty Moore Foundation from January 2012 through June 2013.

Interventions: This was a pilot evaluation study to identify factors that facilitated/hindered the implementation of the ABCDE bundle, interventions designed to decrease the prevalence of ICU-acquired delirium and muscle weakness. The ABCDE bundle consists of spontaneous awakening trials, spontaneous breathing trials, coordination of awakening and breathing trials, choice of sedation, delirium screening and treatment, and early progressive mobility.

Measurements: Process data related to bundle element compliance were collected at baseline and monthly during the intervention period. Outcome data (average ICU length of stay and average days on mechanical ventilation) were collected at baseline and quarterly during the intervention period. Hospital-specific results of the online contextual factors survey and information gathered through interviews and observations during site visits also contributed to the analysis.

Main Results: Factors related to structural characteristics of the ICU, an organizational-wide patient safety culture, an ICU culture of quality improvement, implementation planning, training/support, and prompts/documentation are believed to have facilitated the rate and success of ABCDE bundle implementation. Excessive turnover (both in project and ICU leadership), staff morale issues, lack of respect among disciplines, knowledge deficits, and excessive use of registry staff are believed to have hindered implementation.

Conclusions: Successful implementation of the elements of the ABCDE bundle can result in significant improvements in ICU patient care. The results of this study highlight specific structural and cultural elements of ICUs and hospitals that can positively and negatively influence the implementation of complex care bundles like the ABCDE bundle. Further research is needed to assess the influence of these contextual factors across a broader variety of ICUs and hospitals.

1Cynosure Health, Roseville, CA.

2Department of Anesthesia, Stanford University School of Medicine, Stanford, CA.

3Anesthesiology Service, VA Palo Alto Health Care System, Palo Alto, CA.

4RAND Corporation, Santa Monica, CA.

5Pardee RAND Graduate School, Santa Monica, CA.

6Division of Pulmonary and Critical Care Medicine and Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN.

7Geriatric Research Education Clinical Center, Veterans Administration, Tennessee Valley, Nashville, TN.

Supported, in part, by the Gordon and Betty Moore Foundation.

Dr. Carrothers’ institution received funding from the Gordon and Betty Moore Foundation and the California HealthCare Foundation. Dr. Barr has received an honorarium and travel expenses from SCCM and payment for lectures from Cynosure Health. Dr. Spurlock’s institution received funding from the Gordon and Betty Moore Foundation, part of which supported his travel and work on this manuscript; he also is the Executive Director and a board member at Cynosure Health, which consults for national, state, and local organizations on quality improvement and safety activities. Ms. Ridgely has received honoraria from Cynosure Health. Dr. Damberg has received an honorarium and travel expenses from Cynosure Health, and her institution has received grant funding from the National Institutes of Health. Dr. Ely has received honoraria from Hospira, Orion, and Abbott and is a consultant for Masimo.

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© 2013 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins