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Improving Hospital Survival and Reducing Brain Dysfunction at Seven California Community Hospitals: Implementing PAD Guidelines Via the ABCDEF Bundle in 6,064 Patients*

Barnes-Daly, Mary Ann MS, RN, CCRN, DC; Phillips, Gary MAS; Ely, E. Wesley MD, MPH, FCCM

doi: 10.1097/CCM.0000000000002149
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Objectives: To track compliance by an interprofessional team with the Awakening and Breathing Coordination, Choice of drugs, Delirium monitoring and management, Early mobility, and Family engagement (ABCDEF) bundle in implementing the Pain, Agitation, and Delirium guidelines. The aim was to study the association between ABCDEF bundle compliance and outcomes including hospital survival and delirium-free and coma-free days in community hospitals.

Design: A prospective cohort quality improvement initiative involving ICU patients.

Setting: Seven community hospitals within California’s Sutter Health System.

Patients: Ventilated and nonventilated general medical and surgical ICU patients enrolled between January 1, 2014, and December 31, 2014.

Measurements and Main Results: Total and partial bundle compliance were measured daily. Random effects regression was used to determine the association between ABCDEF bundle compliance accounting for total compliance (all or none) or for partial compliance (“dose” or number of bundle elements used) and outcomes of hospital survival and delirium-free and coma-free days, after adjusting for age, severity of illness, and presence of mechanical ventilation. Of 6,064 patients, a total of 586 (9.7%) died before hospital discharge. For every 10% increase in total bundle compliance, patients had a 7% higher odds of hospital survival (odds ratio, 1.07; 95% CI, 1.04–1.11; p < 0.001). Likewise, for every 10% increase in partial bundle compliance, patients had a 15% higher hospital survival (odds ratio, 1.15; 95% CI, 1.09–1.22; p < 0.001). These results were even more striking (12% and 23% higher odds of survival per 10% increase in bundle compliance, respectively, p < 0.001) in a sensitivity analysis removing ICU patients identified as receiving palliative care. Patients experienced more days alive and free of delirium and coma with both total bundle compliance (incident rate ratio, 1.02; 95% CI, 1.01–1.04; p = 0.004) and partial bundle compliance (incident rate ratio, 1.15; 95% CI, 1.09–1.22; p < 0.001).

Conclusions: The evidence-based ABCDEF bundle was successfully implemented in seven community hospital ICUs using an interprofessional team model to operationalize the Pain, Agitation, and Delirium guidelines. Higher bundle compliance was independently associated with improved survival and more days free of delirium and coma after adjusting for age, severity of illness, and presence of mechanical ventilation.

1Office of Patient Experience, Sutter Health Systems, Sacramento, CA.

2Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University, Columbus, OH.

3Department of Medicine, Pulmonary and Critical Care and Health Services Research Center, Vanderbilt University School of Medicine, Nashville, TN.

4The Tennessee Valley Veteran’s Affairs Geriatric Research Education Clinical Center (GRECC), Nashville, TN.

*See also p. 363.

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

Dr. Barnes-Daly has received honoraria from the Society of Critical Care Medicine and a grant from the Gordon and Betty Moore Foundation for the ICU Liberation project. Her institution received funding from the Gordon and Betty Moore Foundation. Mr. Phillips received funding from Sutter Health. Dr. Ely has received honoraria from Abbott Laboratories, Hospira, and Orion for continuing medical education activities and is funded by both the National Institutes of Health (NIH) and Veteran’s Affairs Geriatric Research Education Clinical Center. He received support for article research from the NIH and received funding from Orion and Abbott. His institution received funding from the NIH and Hospira.

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For information regarding this article, E-mail: barnesm4@sutterhealth.org

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