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Effectiveness and Safety of the Awakening and Breathing Coordination, Delirium Monitoring/Management, and Early Exercise/Mobility Bundle*

Balas, Michele C. PhD, RN, APRN-NP, CCRN1; Vasilevskis, Eduard E. MD, MPH2,3,4; Olsen, Keith M. PharmD, FCCP, FCCM5,6; Schmid, Kendra K. PhD7; Shostrom, Valerie MS7; Cohen, Marlene Z. PhD, RN, FAAN8; Peitz, Gregory PharmD, BCPS5,6; Gannon, David E. MD, FACP, FCCP9; Sisson, Joseph MD9; Sullivan, James MD10; Stothert, Joseph C. MD, PhD, FCCM, FACS11; Lazure, Julie BSN, RN12; Nuss, Suzanne L. PhD, RN13; Jawa, Randeep S. MD, FACS, FCCM11; Freihaut, Frank RRT14; Ely, E. Wesley MD, MPH, FCCM3,4,15; Burke, William J. MD16

doi: 10.1097/CCM.0000000000000129
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Objective: The debilitating and persistent effects of ICU-acquired delirium and weakness warrant testing of prevention strategies. The purpose of this study was to evaluate the effectiveness and safety of implementing the Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility bundle into everyday practice.

Design: Eighteen-month, prospective, cohort, before-after study conducted between November 2010 and May 2012.

Setting: Five adult ICUs, one step-down unit, and one oncology/hematology special care unit located in a 624-bed tertiary medical center.

Patients: Two hundred ninety-six patients (146 prebundle and 150 postbundle implementation), who are 19 years old or older, managed by the institutions’ medical or surgical critical care service.

Interventions: Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility bundle.

Measurements and Main Results: For mechanically ventilated patients (n = 187), we examined the association between bundle implementation and ventilator-free days. For all patients, we used regression models to quantify the relationship between Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility bundle implementation and the prevalence/duration of delirium and coma, early mobilization, mortality, time to discharge, and change in residence. Safety outcomes and bundle adherence were monitored. Patients in the postimplementation period spent three more days breathing without mechanical assistance than did those in the preimplementation period (median [interquartile range], 24 [7–26] vs 21 [0–25]; p = 0.04). After adjusting for age, sex, severity of illness, comorbidity, and mechanical ventilation status, patients managed with the Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility bundle experienced a near halving of the odds of delirium (odds ratio, 0.55; 95% CI, 0.33–0.93; p = 0.03) and increased odds of mobilizing out of bed at least once during an ICU stay (odds ratio, 2.11; 95% CI, 1.29–3.45; p = 0.003). No significant differences were noted in self-extubation or reintubation rates.

Conclusions: Critically ill patients managed with the Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility bundle spent three more days breathing without assistance, experienced less delirium, and were more likely to be mobilized during their ICU stay than patients treated with usual care.

Supplemental Digital Content is available in the text.

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

2Department of Medicine, Division of General Internal Medicine and Public Health, Section of Hospital Medicine, Vanderbilt University, Nashville, TN.

3Center for Health Services Research, Vanderbilt University, Nashville, TN.

4Geriatric Research, Education, and Clinical Center, Tennessee Valley VA, Nashville, TN.

5Department of Pharmacy Practice, University of Nebraska Medical Center, College of Pharmacy, Omaha, NE.

6Department of Pharmaceutical and Nutrition Care, The Nebraska Medical Center, Omaha, NE.

7Department of Biostatistics, University of Nebraska Medical Center, College of Public Health, Omaha, NE.

8Department of Adult Health and Illness, University of Nebraska Medical Center, College of Nursing, Omaha, NE.

9Division of Pulmonary, Critical Care, Sleep, and Allergy, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE.

10Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE.

11Department of Surgery, University of Nebraska Medical Center, Omaha, NE.

12Department of Adult Critical Care Services, The Nebraska Medical Center, Omaha, NE.

13Department of Nursing Research and Quality Outcomes, The Nebraska Medical Center, Omaha, NE.

14Department of Respiratory Care, The Nebraska Medical Center, Omaha, NE.

15Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University, Nashville, TN.

16Department of Psychiatry, University of Nebraska Medical Center, Omaha, NE.

* See also p. 1280.

The work was performed at 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 and by the National Institute on Aging of the National Institutes of Health (NIH) under award number K23AG040157. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

Dr. Balas is currently a co-investigator on a grant supported by the Alzheimer’s Association and has received honoraria from ProCe, the France Foundation, Hospira, and Hillrom. She received support for article research from the Robert Wood Johnson Foundation (RWJF) Interdisciplinary Nursing Quality Research Initiative (INQRI). Her institution received grant support from the RWJF INQRI and the Alzheimer’s Association (Co-I on mobile monitoring study). Dr. Vasilevskis is currently receiving a Career Development Award from the National Institutes of Health (NIH)-National Institute on Aging (NIA) (5K23AG040157) and received grant support for article research from NIH. Dr. Olsen received support for article research from the RWJF. His institution received grant support from the RWJF (supported, in part, the research related to this manuscript). Dr. Schmid serves as a consultant on the data safety and monitoring board (DSMB) for Puma Biotechnology and, in the past, served as a DSMB consultant for Pfizer and received support for article research from the RWJF. Her institution received grant support from the RWJF INQRI. Dr. Cohen received support for article research from the RWJF. Her institution received grant support from the RWJF. Dr. Sisson is currently receiving a NIH Grant (AA008769-20A1). Dr. Sullivan received support for article research from the RWJF. Dr. Jawa has disclosed that this study was supported by a grant from the RWJF INQRI, but he did not receive any compensation from this grant. Dr. Ely received support from NIA AG-027472 and AG-035117, and he has received honoraria from Hospira, Abbott, and Orion. He consulted for Cumberland and Masimo, received grant support from Lilly, and lectured for Hospira. Dr. Burke has received grant support for clinical studies from the National Institute of Mental Health, NIA, RWJF, Alzheimer Disease Cooperative Studies (ADCS), Forest Laboratories, Astra Zeneca, Vanda Pharmaceuticals, Neosync, Elan/Wyeth/Janssen, Baxter Health Care Corporation, Pfizer, Noven Pharmaceuticals, and Novartis. His institution received support for travel (funds to attend INQRI annual meeting) from the RWJF and grant support from the RWJF (for the research), National Institute of Mental Health (NIMH) (R01 funding), ADCS in collaboration with NIMH and Baxter (grant funds), Pfizer (clinical trial funding), Neosync (clinical trial funding), Vanda Pharmaceuticals (clinical trial funding), Novartis (clinical trial funding), Elan/Wyeth (clinical trial funding), Noven Pharmaceuticals (clinical trial funding), Astra Zeneca (clinical trial funding), and Elan (clinical trial funding). The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: balas.17@osu.edu

© 2014 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins