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Abstract

Introduction: The American College of Critical Care Medicine (ACCM) has developed a clinical practice guideline for the management of pain, agitation, and delirium in adult patients in the Intensive Care Unit. This guideline was based on growing evidence that most critically ill patients are at risk for development of dangerous and potentially hospital induced conditions such as ICU delirium and weakness. The Respiratory Therapy departments in our hospital system embarked on an effort to collaborate and implement an interprofessional bundle approach to reduce these adverse events. Initially the Respiratory Therapists identified barriers to this project including workload and productivity concerns, fear of patient discomfort and asynchrony, and fear of inadvertent extubation during awakening and mobility. Methods: To overcome these barriers a variety of methods were used to engage staff. All Respiratory Therapy staff was invited to attend an educational symposium at which clinical experts presented data on the adverse events caused by current ICU care methods. Volunteers were solicited to be champions of the ABCDE bundle project and were trained on interprofessional team building and use of ‘UP to Date’ to gather evidence to promote evidence based, best practices. The team of volunteers worked with the interprofessional team to develop order sets and procedures to promote best practices such as daily rounds, delirium assessments, correct medication selection, daily awakening and spontaneous breathing trials and early mobility. Historically we tracked ventilator length of stay, we added re-intubation rate to our tracking as a balancing measure. To ensure workload neutrality we decreased routine ventilator monitoring from every 2 hours to every 4 hours. Results: Since implementation, daily interprofessional rounds are occurring, standardized scales are now being used to assess delirium and sedation levels, criteria for pain and sedation medication has been modified, daily awakening and SBT’s are being performed and patients who meet safety screening criteria are being mobilized. Patients are more awake and participating in ventilator weaning trials and mobilization. Ventilator length of stay has decreased with no increase in re-intubation rate. Conclusions: The ABCDE bundle was successfully implemented with high quality clinical outcomes. Management, clinical leaders and staff worked in tandem to remove barriers in conjunction with staff engagement which was critical to successful implementation. Further study is needed to evaluate participation and engagement in use of the bundle.