Unplanned Extubations and Falls During Implementation of an ABCDEF Bundle in a Medical ICU

Abstract

SESSION TITLE: Airway/Mechanical Ventilation SESSION TYPE: Original Investigation Slide PRESENTED ON: Wednesday, November 1, 2017 at 08:45 AM - 10:00 AM PURPOSE: To evaluate the patient safety counterbalance measures of unplanned extubations and patient falls while implementing an ABCDEF bundle (Assess for and management of pain, Both spontaneous awakening trials and spontaneous breathing trials, Choice of sedation and analgesia, Delirium monitoring and management, Early mobility, and Family engagement) in a medical ICU. METHODS: We conducted a case-control and before-after quality improvement study of patients who were admitted to a medical ICU from June 1st to November 30th, 2016. We measured the baseline incidence of unplanned extubations and number of patient falls in the pre- and post- intervention phase (June 1st to July 12th and July 12th to November 30th, respectively). The intervention was carried out in patients on one of the two ICU services (cases) from July 12th to November 30th and involved protocolized huddles that included a multi-professional team (advanced practice providers, physicians, occupational and physical therapists, nurses, respiratory therapists, and pharmacists). RESULTS: The intervention patients had 180 ventilator-days before and 453 ventilator days after the intervention. The control patients had 157 ventilator-days before and 477 ventilator days after the intervention. The unplanned extubation rate before the intervention was 1.7 per 100 ventilator-days (1.7%) for the intervention team (cases) vs. 1.9% for the controls. During the intervention phase, the intervention group’s unplanned extubation rate was 1.1% vs. 2.1% for the control (P=0.23, two-sample test of proportions). There was no significant increase in the unplanned extubation rate for the intervention group (1.7% before vs 1.1% after P=0.54). There were 0 patient falls before the intervention in either group. There were 4 falls among 1048 patient-days in the control group (0.4 per 100 patient-days) during the intervention period and 2 falls among 1441 patient-days in the intervention group (0.1 per 100 patient-days, P<0.11, two-sample test of proportions). None of the falls occured while implementing the mobility protocol. CONCLUSIONS: Following the implementation of the ABCDEF bundle, there was no significant increase in the unplanned extubation or fall rates before and after the intervention, or between cases and controls during the intervention. We observed statistically non-significant trends for fewer unplanned extubations and falls during ABCDEF bundle implementation as a possible signal of additional value of the intervention. CLINICAL IMPLICATIONS: When implementing a quality improvement program, it is important to look at potential adverse effects, or counterbalancing measures, to ensure patient safety is maintained. Although the ABCDEF bundle is part of current Pain Agitation Delirium guidelines, it is not being practiced in many hospitals. Safety concerns, particularly unplanned extubations and falls, have been cited as barriers to implementing the bundle. Our findings suggest that in the setting of multi-professional protocolized huddles, ABCDEF bundle implementation in an academic tertiary care center does not lead to an increased incidence of unplanned extubations or falls, and in fact might be protective. Larger studies are needed to confirm and extend the external validity of these findings. DISCLOSURE: The following authors have nothing to disclose: Erica Schneider, Amy Dean, George Kallingal, Markos Kashiouris, Ashley Daniels, Kim Varney, Martha Booth, Ken-Nisha Norris, Sarah Knizewski, Curtis Sessler, Lois Rowland, Kristin Miller No Product/Research Disclosure Information