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Implementing the Awakening and Breathing Coordination, Delirium Monitoring/Management, and Early Exercise/Mobility Bundle into Everyday Care: Opportunities, Challenges, and Lessons Learned for Implementing the ICU Pain, Agitation, and Delirium Guidelines

Balas, Michele C. PhD, RN, APRN-NP, CCRN1; Burke, William J. MD2; Gannon, David MD3; Cohen, Marlene Z. PhD, RN, FAAN4; Colburn, Lois BES5; Bevil, Catherine RN, EdDl6; Franz, Doug BS7; Olsen, Keith M. PharmD, FCCP, FCCM8,9; Ely, E. Wesley MD, MPH, FCCM10,11; Vasilevskis, Eduard E. MD12,13

doi: 10.1097/CCM.0b013e3182a17064
Creating and Implementing the 2013 ICU Pain, Agitation, and Delirium Guidelines for Adult Icu Patients

Objective: The awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle is an evidence-based interprofessional multicomponent strategy for minimizing sedative exposure, reducing duration of mechanical ventilation, and managing ICU-acquired delirium and weakness. The purpose of this study was to identify facilitators and barriers to awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle adoption and to evaluate the extent to which bundle implementation was effective, sustainable, and conducive to dissemination.

Design: Prospective, before-after, mixed-methods study.

Setting: Five adult ICUs, one step-down unit, and a special care unit located in a 624-bed academic medical center

Subjects: Interprofessional ICU team members at participating institution.

Interventions and Measurements: In collaboration with the participating institution, we developed, implemented, and refined an awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle policy. Over the course of an 18-month period, all ICU team members were offered the opportunity to participate in numerous multimodal educational efforts. Three focus group sessions, three online surveys, and one educational evaluation were administered in an attempt to identify facilitators and barriers to bundle adoption.

Main Results: Factors believed to facilitate bundle implementation included: 1) the performance of daily, interdisciplinary, rounds; 2) engagement of key implementation leaders; 3) sustained and diverse educational efforts; and 4) the bundle’s quality and strength. Barriers identified included: 1) intervention-related issues (e.g., timing of trials, fear of adverse events), 2) communication and care coordination challenges, 3) knowledge deficits, 4) workload concerns, and 5) documentation burden. Despite these challenges, participants believed implementation ultimately benefited patients, improved interdisciplinary communication, and empowered nurses and other ICU team members.

Conclusions: In this study of the implementation of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle in a tertiary care setting, clear factors were identified that both advanced and impeded adoption of this complex intervention that requires interprofessional education, coordination, and cooperation. Focusing on these factors preemptively should enable a more effective and lasting implementation of the bundle and better care for critically ill patients. Lessons learned from this study will also help healthcare providers optimize implementation of the recent ICU pain, agitation, and delirium guidelines, which has many similarities but also some important differences as compared with the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle.

1Center for Critical and Complex Care, The Ohio State University College of Nursing, Columbus, OH.

2Department of Psychiatry, University of Nebraska Medical Center, Omaha, NE.

3Division of Pulmonary, Critical Care, Sleep & Allergy, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE.

4Department of Adult Health and Illness, College of Nursing, University of Nebraska Medical Center, Omaha, NE.

5Center for Continuing Education, University of Nebraska Medical Center, Omaha, NE.

6Department of Continuing Nursing Education and Evaluation, College of Nursing, University of Nebraska Medical Center, Omaha, NE.

7College of Medicine, University of Nebraska Medical Center, Omaha, NE.

8Department of Pharmacy Practice, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE.

9Department of Pharmaceutical and Nutrition Care, The Nebraska Medical Center, Omaha, NE.

10Geriatric Research, Education and Clinical Center, VA–Tennessee Valley, Nashville, TN.

11Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University, Nashville, TN.

12Section of Hospital Medicine, Division of General Internal Medicine, Department of Medicine, Vanderbilt University, Nashville, TN.

13Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University, Nashville, TN.

This work was performed in The Nebraska Medical Center.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).

Supported, in part, by the Robert Wood Johnson Foundation Interdisciplinary Nursing Quality Research Initiative.

Dr. Balas is currently a coinvestigator on a grant supported by the Alzheimer’s Association; has received honoraria from Hospira, Proce, France Foundation, and Hill-Rom; and is a consultant for the Centers for Disease Control and Cynosure Health; her institution has received a grant from the Robert Wood Johnson Foundation Interdisciplinary Nursing Quality Research Initiative. Dr. Burke has received a grant and support for travel from the Robert Wood Johnson Foundation and grant support for clinical studies from the National Institute of Mental Health, National Institute on Aging, Alzheimer Disease Cooperative Studies, Forest Laboratories, Astra Zeneca, Vanda Pharmaceuticals, Neosync, Elan/Wyeth/Janssen, Baxter Health Care Corporation, Pfizer, Noven Pharmaceuticals, and Novartis. Dr. Gannon's institution received funding from the Robert Wood Johnson Foundation. Dr. Cohen has current funding from the National Institutes of Health/National Institute of Nursing Research, and her institution has received a grant from the Robert Wood Johnson Foundation. Dr. Bevil's institution has received funding from the Robert Wood Johnson Foundation and the Health Resources and Services Administration. Dr. Olsen is a member of American College of Critical Care Medicine Board of Regents, the body that approved the PAD guideline. Dr. Ely has received honoraria from Hospira, Orion, and Abbott and is a consultant for Cumberland and Masimo. Dr. Vasilevskis is supported by the National Institutes of Health (K23AG040157), the Veterans Affairs Clinical Research Center of Excellence, and the Geriatric Research, Education, and Clinical Center. The authors’ funding sources did not participate in the planning, collection, analysis, or interpretation of data or in the decision to submit for publication. The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: mbalas@unmc.edu

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