Implementation Strategies Used to Facilitate ABCDEF Bundle Adoption
Implementation Strategies Used to Facilitate ABCDEF Bundle Adoption: a scoping review Paige Donahue; Michele Balas, Ph. D, RN, CCRN-K, FCCM, FAAN “Knowing is not enough; we must apply. Willing is not enough; we must do. ” (Johann Wolfgang von Goethe) Introduction/Background Methods/Measurements • The COVID-19 pandemic has created a sudden & unprecedented demand for mechanical ventilation (MV) & intensive care unit (ICU) services. To reduce the morbidity & mortality associated with this respiratory pandemic, evidence-based ICU interventions need to be effectively & reliably applied into ICU practice. • This scoping review adheres to the Preferred Reporting Items for Systematic reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-Sc. R) checklist. • Electronic databases CINAHL, Pub. Med, Web of Science, Scopus, and Embase were searched for studies published from 20092020 using the search terms “ABCDEF bundle” OR “ABCDE bundle”. • The ABCDEF bundle (Table 1) is an evidence-based, integrated, and teambased guide to MV liberation, symptom management, & ICU physical activity. ABCDE Bundle ABCDEF Bundle Awakening & Breathing Coordination Delirium monitoring & management Early mobility & exercise Assess, prevent, & manage pain Both SATs & SBTs Choice of analgesia & sedation Delirium: Assess, prevent & manage Early mobility & exercise Family engagement & empowerment • While associated with significant improvements in ICU & hospital survival, MV duration, and coma and delirium rates, ¹ studies consistently demonstrate the ABCDEF bundle is currently grossly underutilized. ² • This knowledge-to-practice gap is likely caused by the numerous, well-described barriers clinicians experience when trying to implement the ABCDEF bundle into everyday ICU care. Aims/Purpose The purpose of the scoping review was to identify & critically evaluate the strategies past research studies & quality improvement (QI) projects used to facilitate ABCDEF bundle implementation. • After screening 368 titles/abstracts & reviewing 23 full-text studies, 10 studies were deemed eligible for inclusion. Of these 10 studies, 4 manuscripts reported the implementation methods used in 2 discrete collaborative initiatives. Thus, in total, 8 discrete implementation efforts were analyzed. CINAHL n=70 Web of Science n=127 Pub. Med n=57 SCOPUS n=69 EMBASE n=131 After duplicates removed n=368 After initial screening n=23 Studies included in review n=10 Figure 2. Study inclusion/exclusion Titles/abstracts excluded n=345 Full text articles excluded n=13 Focus on provider perception, not implementation (6) Offered results of bundle implementation, but did not detail implementation strategies (4) Detail current state of ABCEF bundle practices, not implementation of the bundle (3) Author, Year Setting/sample size Design Balas, 2013 463 adults in a 624 -bed academic medical center 296 adults in a 624 -bed academic medical center 6064 MICU/SICU patients from 7 community hospitals Over 17, 000 from 75 ICUs 81 ICU providers from open/mixed MICU, SICU 1855 MV adults in 2 ICUs 83 adults in one ICU Prospective, before-after, mixed-methods study Prospective, cohort, beforeafter Prospective cohort quality improvement initiative QI project Balas, 2014 Barnes-Daly, 2016 Barnes-Daly, 2018 Carrothers, 2013 Hsieh, 2015 Kram, 2015 Pun, 2019 Ren, 2017 Sosnowski, 2018 ABCDE or ABCDEF Bundle ABCDE Number of strategies used 43 ABCDEF 37 ABCDEF ABCDE 54 39 Prospective cohort study ABCDE QI pre/post implementation ABCDE 15, 226 adults (MV or no MV) Prospective, multicenter, ABCDEF from 68 ICUs cohort study from a national QI collaborative 143 adults on MV in one ICU Cross-sectional overall, ABCDE before-after controlled study 30 MV adults from one ICU Prospective, single center, ABCDE randomized controlled feasibility study 36 36 54 8 32 Results/Findings Discussion • The average number of implementation strategies used per project was 35. 6 (SD=12. 9) • Number of strategies used ranged from eight to 54 • Strategies used by all eight efforts: • Develop an implementation glossary • Develop educational materials • Facilitation • Provide clinical supervision • Recruit, designate, and train for leadership • Financial disincentives were not used by any studies • No studies evaluated the effectiveness of individual implementation strategies • Patient and family-driven implementation strategies were only mentioned by one implementation effort; this was one of two efforts implementing the ABCDEF bundle • Future evaluation of implementation strategies is essential to effectively allocate efforts and resources • Research trials must identify, test, and report the specific methods and resources needed for effective and sustained ABCDEF bundle implementation • Until effective implementation is understood, the excessively high morbidity, mortality, and cost associated with standard critical care delivery will continue and the public health benefit of the ABCDEF bundle will not be fully realized. References 1. Pun, B. T. , Balas, M. C. , Barnes-Daly, M. A. , Thompson, J. L. , Aldrich, J. M. , Barr, J. , Byrum, D. , Carson, S. S. , Devlin, J. W. , Engel, H. J. , Esbrook, C. L. , Hargett, K. D. , Harmon, L. , Hielsberg, C. , Jackson, J. C. , Kelly, T. L. , Kumar, V. , Millner, L. , Morse, A. , Perme, C. S. , … Ely, E. W. (2019). Caring for Critically Ill Patients with the ABCDEF Bundle: Results of the ICU Liberation Collaborative in Over 15, 000 Adults. Critical care medicine, 47(1), 3– 14. https: //doi. org/10. 1097/CCM. 0000003482 2. Costa, D. K. , White, M. R. , Ginier, E. , Manojlovich, M. , Govindan, S. , Iwashyna, T. J. , & Sales, A. E. (2017). Identifying Barriers to Delivering the Awakening and Breathing Coordination, Delirium, and Early Exercise/Mobility Bundle to Minimize Adverse Outcomes for Mechanically Ventilated Patients: A Systematic Review. Chest, 152(2), 304– 311. https: //doi. org/10. 1016/j. chest. 2017. 03. 054.
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