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Staged Implementation of Awakening and Breathing, Coordination, Delirium Monitoring and Management, and Early Mobilization Bundle Improves Patient Outcomes and Reduces Hospital Costs*

Hsieh, S. Jean MD, MS1; Otusanya, Olufisayo MD2; Gershengorn, Hayley B. MD3; Hope, Aluko A. MD, MScE4; Dayton, Christopher MD5; Levi, Daniela MD4; Garcia, Melba BSN6; Prince, David MD7; Mills, Michele MA, OTR8; Fein, Dan MD9; Colman, Silvie PhD10; Gong, Michelle Ng MD, MS4,11

doi: 10.1097/CCM.0000000000003765
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Objectives: To measure the impact of staged implementation of full versus partial ABCDE bundle on mechanical ventilation duration, ICU and hospital lengths of stay, and cost.

Design: Prospective cohort study.

Setting: Two medical ICUs within Montefiore Healthcare Center (Bronx, NY).

Patients: One thousand eight hundred fifty-five mechanically ventilated patients admitted to ICUs between July 2011 and July 2014.

Interventions: At baseline, spontaneous (B)reathing trials (B) were ongoing in both ICUs; in period 1, (A)wakening and (D)elirium (AD) were implemented in both full and partial bundle ICUs; in period 2, (E)arly mobilization and structured bundle (C)oordination (EC) were implemented in the full bundle (B-AD-EC) but not the partial bundle ICU (B-AD).

Measurements and Main Results: In the full bundle ICU, 95% patient days were spent in bed before EC (period 1). After EC was implemented (period 2), 65% of patients stood, 54% walked at least once during their ICU stay, and ICU-acquired pressure ulcers and physical restraint use decreased (period 1 vs 2: 39% vs 23% of patients; 30% vs 26% patient days, respectively; p < 0.001 for both). After adjustment for patient-level covariates, implementation of the full (B-AD-EC) versus partial (B-AD) bundle was associated with reduced mechanical ventilation duration (–22.3%; 95% CI, –22.5% to –22.0%; p < 0.001), ICU length of stay (–10.3%; 95% CI, –15.6% to –4.7%; p = 0.028), and hospital length of stay (–7.8%; 95% CI, –8.7% to –6.9%; p = 0.006). Total ICU and hospital cost were also reduced by 24.2% (95% CI, –41.4% to –2.0%; p = 0.03) and 30.2% (95% CI, –46.1% to –9.5%; p = 0.007), respectively.

Conclusions: In a clinical practice setting, the addition of (E)arly mobilization and structured (C)oordination of ABCDE bundle components to a spontaneous (B)reathing, (A)wakening, and (D) elirium management background led to substantial reductions in the duration of mechanical ventilation, length of stay, and cost.

1Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.

2Division of Pulmonary Diseases, Critical Care, and Environmental Medicine, Department of Medicine, Tulane University School of Medicine, New Orleans, LA.

3Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, University of Miami, Miller School of Medicine, Miami, FL.

4Division of Critical Care Medicine, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY.

5Division of Pulmonary Diseases and Critical Care, Department of Medicine, University of Texas Health Sciences Center at San Antonio, San Antonio, TX.

6Department of Nursing, Montefiore Healthcare Center, Bronx, NY.

7Department of Physical Medicine and Rehabilitation, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY.

8Occupational Therapy Assistant Program, Health Sciences Department, LaGuardia Community College, Long Island City, NY.

9Division of Pulmonary Medicine, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY.

10Network Performance Group, Montefiore Medical Center, Yonkers, NY.

11Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY.

*See also p. 997.

Drs. Hsieh and Gong conceptualized and designed the study. Drs. Hsieh, Otusanya, Gershengorn, Hope, Dayton, Prince, Mills, Fein, Colman, and Gong acquired, analyzed, and interpreted the data. Drs. Hsieh, Otusanya, Gershengorn, Hope, and Gong drafted the article for important intellectual content.

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 8KL2TR0000088-05 from the Albert Einstein College of Medicine - Montefiore Medical Center Institute for Clinical and Translational Research (to Dr. Hsieh), R03AG050927 (to Dr. Hope), National Heart, Lung, and Blood Institute HL084060 and HL086667 (to Dr. Gong); 1 UL1 TR001073-01, 1 TL1 TR001072-01, 1 KL2 TR001071-01 (Einstein-Montefiore Clinical and Translational Science Awards).

Drs. Hsieh, Hope, and Gong received support for article research from the National Institutes of Health (NIH). Dr. Hsieh’s institution received funding from Einstein-Montefiore Institute for Clinical and Translational Research and La Jolla Pharmaceutical. Dr. Gong’s institution received funding from NIH grants and Philips Healthcare. The remaining authors have disclosed that they do not have any potential conflicts of interest.

This work was performed at Montefiore Healthcare Center.

Address requests for reprints to: Michelle Ng Gong, MD, MS, Division of Critical Care Medicine, Department of Medicine, Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467. E-mail: mgong@montefiore.org

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