ABCDEF Bundle Breakout
Andrew Masica, MD, MSCIVP, Chief Clinical Effectiveness Officer
Baylor Scott & White Health
Disclosures/Funding Support
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Grant R18-HS021459 from the Agency for Healthcare Research and Quality (AHRQ) funded portions of this work. The findings and conclusions in this program are those of the author, who is responsible for its content, and do not necessarily represent the views of AHRQ.
Baylor Scott & White Research institute holds research grants from the following companies on which Dr. Masica is an investigator: Pfizer, Mallinckrodt, Medtronic.
These research grants are unrelated to the presentation content. No commercial products or services will be referenced.
Learning Objectives
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1. Articulate ABCDEF bundle care processes, eligibility criteria, and safety parameters
2. Delineate specific EHR workflows to facilitate ABCDEF Bundle adoption and reliable use by front-line staff
3. Interpret and apply ABCDEF reports to help guide ICU quality improvement efforts
ABCDEF: A Bundle of Best Practices
ABCD Bundle
Delirium assessment, prevention,
and management
ABCD Bundle which will be deployed across Intermountain Healthcare
E
Assess for, prevent, and manage pain
Both spontaneous
awakening trial (SAT)
and spontaneous
breathing (SBT) trial
Choice to use (and of)
analgesia and sedation
Delirium assessment, prevention,
and management
Early activity and mobility
E
ABCDE Bundle
DCBA
F=Family Engagement
Synergy of the ABCDEF Bundle
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ABCDEF Bundle Safety Parameters
Adapted from Girard TD et al, Lancet 2008
Bundle Eligibility
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• Inclusion Criteria– 18 years of age or older– ICU admission lasting >24 hours– On the ventilator for >48 hours and <14 days
• Exclusion Criteria– On comfort/hospice care– Pending transfer to non-ICU bed– Never on the ventilator– Physician opt-out
Bundle currently used across all ICU-types/specialties
ABCDEF Bundle Implementation TacticsAdoption Program Component Time to Completion
Activate Nurse/ Physician Champions and secure clinical staff conceptual buy-in
1-2 months (based on hospital size)
Assess current state (workflow, performance) 1-month
Development of supportive EHR Documentation and order set with incorporation into production (live use) environment
9-12 months
Training Sessionsa. “Train the trainer”b. Frontline staffc. E-learning modules
4-6 month cycle to launch each unit; multiple “reinforcement” sessions required.
Use of daily rounding tool 9-12 months
Standardized Performance Reporting (hospital and unit levels)
4 months after completion of EHR workflow tools
Optimization/EHR refinement/standing meetings Ongoing
Accountability as a system critical care goal 3 months after standardized reporting
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Identify Stakeholders
VP of Medical Affairs/ CMO
Hospital and Unit Directors
Nursing
Physicians
RT
PT/OT
Pharmacy
IT
Quality Improvement
Patient Safety
Collaborative Patient Care Team
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Interdisciplinary Effort
Respiratory
PT/OT
Physicians
Nursing
Pharmacists
Automated Bundle Activation
(Opt-Out Order Set)
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Assess for, Prevent and Manage Pain
• CPOT for intubated patients• Pain Intensity Scale for verbal patients• Assessments every 2 hours for ICU level care
Sedation Vacation-Structured Note
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Breathing Trial-Structured Note
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CONFIDENTIAL - Internal Use Only 16
Choice to use (and of) Analgesia and Sedation
Sample ICU Cohort
Opioid Related ADEs: Surgical Patients(N=135,000)
17Baylor Scott & White Health – Proprietary and Confidential Document
ORADE Descriptions Severity ICD9 Codes N (%)
Respiratory 9,437 (49%)
Pulmonary congestion & hypostasis Mild 514 172 (2%)
Pulmonary insufficiency following surgery and trauma
Respiratory complications
Other pulmonary insufficiency, not elsewhere classified
Moderate
518.5X
997.3X
518.82
1,386 (15%)
Bradypnea Moderate 786.09 301 (3%)
Acute respiratory failure Severe 518.81 1,897 (20%)
Hypoxemia
HypoxiaModerate
799.02
977.011,151 (13%)
Mechanical ventilator Severe 96.7X 4,530 (48%)
Central Nervous System 1,431 (7%)
Delirium
Altered mental status
Confusion – classified otherwise
Moderate
780.09
780.97
293.xx
1,426 (99%)
Nervousness Mild 799.2X 4 (<1%)
Dizziness/vertigo Mild 386.2 1 (<1%)
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Test Description Performance
Confusion Assessment Method(Long Form)
Generally used in research Gold Standard
Confusion Assessment Method-Intensive Care Unit (CAM-ICU)
Bedside clinical applicationAdapted for Non-verbal patients
Sensitivity-80%Specificity-96%
Intensive Care Unit Delirium Screening Checklist (ICSDC)
Point scoring system Sensitivity-74%Specificity-89%
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Tests to Detect Delirium-ICU
Gusmao-Flores D et al. The confusion assessment method for the intensive care unit (CAM-ICU) and intensive care delirium screening checklist (ICDSC) for the diagnosis of delirium: a systematic review and meta-analysis of clinical studies. Critical Care 2012 16:R115.
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Test Description Performance
Confusion Assessment Method(Long Form)
Generally used in research Gold Standard
Confusion Assessment Method(Short Form)
First 4 items of full CAMBedside clinical applicationShould be scored with cognitive screen
Sensitivity-94%Specificity-89%
Ultrabrief Screening 2 questions“Months of year backwards”“What is the day of the week?”
Sensitivity-93%Specificity-64%
3D Confusion Assessment Method Short CAM + embedded cognitive screen3D=3 minutes, diagnostic
Sensitivity-95%Specificity-94%
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Other Delirium Tests
https://www.hospitalelderlifeprogram.org/delirium-instruments/
Fick et al, Preliminary Development of an Ultrabrief Two-Item Bedside Test for Delirium, J Hosp Med 2015
Kuczmarka et al, Detection of Delirium in Hospitalized Older General Medicine Patients: A Comparison of the 3D-CAMand CAM-ICU, J Gen Intern Med 2015
Sedation and Delirium AssessmentCAM-ICU
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CAM-ICU Decision Support
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Exercise/Mobility Documentation
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It’s All About Family
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Real-Time Reporting for “Measure-Vention”
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Bundle Inclusion in Team Rounds/Unit Huddles
Training/Education
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“Super-trainer” course:
Capability of teaching peers in CAM-ICU (including teach-back)
High degree of acumen with EHR changes
Case studies
Basic course for frontline staff:
Understand components of the ABCDE bundle and ways to incorporate those processes into routine clinical care
Identify potential barriers and facilitators to implementation of the ABCDE bundle
Become comfortable with bundle related changes in the EHR
Development of e-learning modules
Provider Accountability
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Goal: For ICU patients with acute respiratory failure requiring mechanical ventilation for ≥ 24 hours, adherence to specific components of the ventilator management bundle (daily awakening trials, spontaneous breathing trials, delirium screening, early mobility). The denominator will be based on the # of observations for which the patient is eligible (i.e. had an appropriate indication and met safety criteria to receive that process) on a daily basis. Observations after > 14 days on mechanical ventilation will be excluded. Points assigned for process performance levels and added cumulatively.
Performance Targets:
Daily Awakening Trial: 60-70% (1 point); 71-80% (2 points), above 80% (3 points)
Breathing Trials: 60-70% (1 point); 71-80% (2 points); above 80% (3 points)
Delirium Screening: 70-80% (1 point), 81-90% (2 points); above 90% (3 points)
Exercise/Mobility: 50-60% (1 point); 61-70% (2 points); above 70% (3 points)
Composite Bundle: 50-60% (1 point), 61-70% (2 points), above 70% (3 points)
D
E
B
A
Reporting: SAT and SBT
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Reporting: Delirium Metrics
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Reporting: Mobility
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Reporting: Mobility Detail
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Reporting: Composite Bundle
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Interrater Reliability of CAM-ICU
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Performance of CAM-ICU in Eligible Patients Inter-rater Reliability of CAM-ICU
Pre Post Pre Post
Patients with documented
CAM-ICU (%)
Patients with documented
CAM-ICU (%)
Paired cases
N
Kappa Coefficient (95% CI)
Paired cases
N
Kappa Coefficient (95% CI)
Tertiary Hospital
65 84* 183 0.53 (0.43-0.63)
149 0.71 (0.62-0.80)
Community Hospital
70 85* 41 0.49 (0.29-0.68)
16 0.89 (0.69-1.00)
Combined 66 84* 224 0.53 (0.44-0.61)
165 0.73 (0.64-0.81)
*P-value <0.05
Composite Bundle Uptake by Intervention Group
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Apr-15
Maintaining at > 90%
Individual Bundle Element Adherence Trends
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Baseline Population Characteristics(by Bundle Adherence Level)
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Adherence Level
25-50%
N=1004
50-75%
N=1539
75-100%
N=1317
p-value
Age, mean (SD) 61.77 (15.21) 60.56 (15.47) 60.19 (15.64) 0.0562
Gender (male), n (%) 460 (51) 523 (58) 504 (55) 0.0046*
Race, n (%)
White 605 (67) 926 (66) 877 (71) 0.0106*
Black 252 (28) 418 (30) 308 (25)
Other 50 (6) 60 (5) 54 (5)
Hispanic n (%) 127 (14) 108 (11) 114 (13) 0.3283
Insurance, n (%)
Private 111 (12) 205 (15) 182 (15) 0.1736
Medicare 501 (55) 742 (53) 612 (49)
Medicaid 51 (6) 72 (5) 61 (5)
Other 244 (26) 385 (26) 386 (27)
APACHE Score, mean (SD) 19.12 (6.73) 18.27 (6.29) 18.03 (6.43) 0.0004*
Charlson Comorbidity Index, mean (SD) 5.06 (2.86) 4.70 (2.75) 4.51 (2.78) <.0001*
APR DRG Severity, n (%)
3 68 (8) 162 (12) 192 (15) <.0001*
4 837 (92) 1233 (88) 1026 (83)
APR-DRG Mortality Risk, n (%)
3 129 (14) 308 (22) 359 (29) <.0001*
4 762 (84) 1057 (75) 838 (68)
Surgical, n (%) 94 (10) 166 (18) 161 (18) <.0001*
Dementia, n (%) 70 (8) 63 (7) 61 (7) 0.6833
Alcohol, n (%) 21 (2) 23 (2) 17 (2) 0.3473
Current Smoker, n (%) 172 (19) 187 (21) 193 (21) 0.3926
Impact on Delirium and Coma Outcomes(Risk Adjusted for Illness Severity):
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Medium Adherence
50-75%
(n = 1337)
High Adherence
75-100%
(n = 869)
Risk-adjusted Outcomes Estimate CI Estimate CI
Incidence of delirium (OR) 1.49* (1.21, 1.84) 1.73* (1.37, 2.18)
Duration of delirium (days)a 0.10 (-0.08, 0.29) 0.23 (-0.04, 0.50)
Incidence of coma (OR) 0.67* (0.51, 0.88) 0.53* (0.40, 0.71)
Duration of coma (days)b -0.32* (-0.37, -0.27) -0.52* (-0.72, -0.33)
% Coma/delirium free days 0.18* (0.13, 0.23) 0.23* (0.13, 0.33)
Comparison Group: 25%-50% Composite Bundle Adherence
aFor patients diagnosed with deliriumbFor patients diagnosed with coma
*p < 0.05
Impact on Additional Clinical Outcomes(Risk Adjusted for Illness Severity):
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Medium Adherence
50-75%
(n = 1337)
High Adherence
75-100%
(n = 869)
Risk-adjusted Outcomes Estimate CI Estimate CI
ICU Length of Staya 0.03 (-0.05, 0.11) 0.04 (-0.05, 0.12)
Hospital Length of Staya 0.00 (-0.04, 0.03) -0.03 (-0.08, 0.03)
Ventilator days -0.05 (-0.14, 0.03) -0.20* (-0.36, -0.05)
Mobilized out of bed (OR) 2.49* (1.97, 3.15) 3.97* (3.05, 5.16)
Discharged home (OR) 1.76* (1.41, 2.21) 2.16* (1.69, 2.75)
Inpatient mortality (OR) 0.39* (0.31, 0.48) 0.25* (0.19, 0.31)
Comparison Group: 25%-50% Composite Bundle Adherence
aPatients who died during ICU stay were excluded from LOS calculations
*p < 0.05
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Bundle Program Clinical Implications
Higher use of the ABCDEF bundle across a “real-world” setting (multiple hospitals in a heterogeneous delivery organization) was associated with improvements in several patient-centered outcomes.
Deployment of the bundle likely unmasks cases of “hidden” ICU delirium rather than a true incidence increase; % of days awake without delirium increased with higher adherence levels.
We have observed ongoing opportunities to improve physician response to recognized cases of delirium and with mobilization.
The bundle is gaining momentum as a patient safety practice; several collaboratives to promote adoption are underway.
The financial savings may accrue more from reduced post-acute carecost reduction (i.e. 90-day costs rather than inpatient stay)
Questions/Discussion
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