The focus on long-term consequences of critical illness has intensified with increasing ICU utilization and survivorship (1). Postintensive care syndrome (PICS), characterized by a constellation of physical, cognitive, and emotional manifestations, is increasingly recognized and has profound and long-lasting negative impacts on ICU survivors as well as their families and caregivers (2). The exact mechanisms for the development of PICS are unknown (2). Although some aspects of PICS may simply be intrinsic to critical illness and inevitable, avoiding iatrogenic practices linked to harm is an essential aspect to the effective delivery of critical care (1).
The ABCDEF bundle is an organizational approach to screen for and treat a series of variables affecting intensive care patients in an evidence-based manner and is designed to limit iatrogenic harms and improve the care of the critically ill (3). The individual elements of the bundle originate from seminal ICU research and have undergone iterative development since their initial inception (1, 3). In its current form, the bundle consists of the following components: A—Assess, prevent, and manage pain; B—Both spontaneous awakening trials and spontaneous breathing trials; C—Choice of analgesia and sedation; D—assess, prevent, and manage Delirium; Early mobility and exercise; and F—Family engagement and empowerment (Society of Critical Care Medicine [SCCM]). Previous work demonstrates bundle implementation improved meaningful clinical outcomes including duration of mechanical ventilation, delirium, frequency of mobilization, and survival, and higher bundle compliance is associated with incremental improvements in rates of survival, delirium, and coma, suggesting a possible dose-response effect (4, 5). Recently, the SCCM embarked on the ICU Liberation Collaborative, a large-scale quality improvement initiative in 76 ICUs across the United States designed to facilitate application of the Pain, Agitation, and Delirium Guidelines through ABCDEF bundle implementation (1, 6). The initial findings from this effort were recently published, and bundle performance was associated with improvement in many significant clinical outcomes including survival, mechanical ventilation use, coma, delirium, restraint-free care, ICU readmissions, and post-ICU discharge to facility rather than home (7).
In this issue of Critical Care Medicine, Hsieh et al (8) share their experience with staged implementation of ABCDE bundle components at a single academic medical center, comparing outcomes in adult mechanically ventilated patients during full and partial bundle implementation in two separate ICUs. It is first important to note that the bundle component definitions were the initial iteration, that is, before pain assessment and management had been added to the bundle: A—Awakening from sedation; B—Breathing trials; C—Coordinate bundle components, D—Delirium monitoring/management; E—Early mobilization, and F was not yet part of the bundle. At baseline, both ICUs already performed component B. The first stage of implementation added the A and D components to both ICUs, and the second added the E and C components only to the full bundle ICU (B-AD-EC) but not the partial bundle ICU (B-AD). In total, 1,855 patients were captured during the baseline and implementation periods between the two ICUs. The addition of E and C during the second implementation stage improved patient mobilization and reduced both ICU-acquired pressure ulcers and restraint use in the full bundle ICU. Comparing the full and partial bundle ICUs, full implementation was associated with significant reductions in duration of mechanical ventilation (–22.3%) and both ICU and hospital length of stay, –10.3% and –7.8%, respectively. Finally, full bundle implementation reduced total hospital cost by 30.2% relative to partial bundle implementation, and the addition of E and C to the full bundle ICU reduced costs in that ICU by 24.2%. Both of these findings likely related to the reduction in length of stay as the average daily ICU cost was not reduced over the course of the study.
There are several limitations to this observational analysis. First, baseline differences in the staffing models and patient populations existed between the ICUs. Additionally, nursing plays a central role in executing the bundle components; the differences between the baseline pressure ulcer rates and restraint use suggest variation in nursing practices between the units. These factors potentially could have affected the results. Importantly, the authors used difference-in-difference analyses to account for preexisting temporal trends and variation inpatient level variables in an effort to minimize the impacts of these differences on their results. The single center design of the study by Hsieh et al (8) limits generalizability. With this in mind, some readers may be concerned about the validity of the large effect sizes of the intervention. Reassuringly, prior work examining bundle implementation also showed large effect sizes (4, 5). Finally, process measures, linking effective bundle delivery to outcomes, were only measured in the full bundle ICU and not the partial bundle ICU.
The work of Hsieh et al (8) adds to the growing literature describing the positive impacts of the ABCDEF bundle, further cementing its role as a framework for evidence-based critical care delivery. Notably, this is the first report describing cost benefits in addition to improvement in patient outcomes with bundle implementation, a key finding to demonstrate bundle value from an organizational management standpoint. Previous studies evaluated the positive effects of simultaneous implementation of all bundle components (4, 5, 7), and this work demonstrates staged implementation, a task that may be more practical depending on the institutional resources, is both feasible and efficacious. Furthermore, partial bundle implementation is the current state of practice for many ICUs (9). This work provides those institutions not only with evidence to support further bundle implementation but also a tangible implementation roadmap to get from A to F, not just A to B.
Unfortunately, integration of evidence-based interventions into clinical practice frequently suffers from significant time delay and may never consistently happen (10, 11). Critical care is not exempt from this phenomenon as shown in a recent international analysis of acute respiratory distress syndrome care demonstrating suboptimal application of lung protective ventilation (12). Although a more recent innovation, ABCDEF bundle application is known to be inconsistent across ICUs (8). One solution to this larger problem may be the growing field of implementation science, which seeks to understand barriers contributing to the slow adoption of clinical therapeutics and discover effective strategies to accelerate change (13). Early mobility, a single component of the bundle, has 28 unique barriers to implementation, which may explain why multicomponent implementation strategies have been more successful with other bundle components (14, 15). Kotter (16), a seminal leader in the field of organizational change, may have said it best—“Innovation is less about generating brand new ideas and more about knocking down barriers to making those ideas a reality.” For this reason, implementation experiences such as Hsieh et al (8) and ICU Liberation Collaborative are important additions to the field, furthering our understanding of the “how” in implementation. As the pace of research quickens and care delivery becomes more complex, understanding how to more effectively translate evidence into clinically actionable care becomes just as important as the discovery of the initial intervention.
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