Building a Better ICU by the Letter: the ABCDEF Bundle Improvement Collaborative

2016 - 2 April - SCCM’s Quality Improvement Initiatives
Read about SCCM’s ABCDEF Bundle Improvement Collaborative.

A host of critical care providers across the country have been studying their ABCs for more than a decade—the ABCs that comprise a bundle of standardized protocols structured to eliminate intensive care unit (ICU) delirium, along with the cognitive dysfunction and physical weakness that all too often accompany even a short ICU stay. These debilitating conditions, results of the heavy sedation, ventilator use and immobilization historically standard in ICU care—often referred to as post-ICU syndrome—may leave patients permanently impaired or disabled, and may also contribute to more readmissions and higher mortality rates.

The original ABCDE bundle of evidence-based ICU protocols has evolved through multiple critical care studies over the past 15 years. The letters originally stood for Awakening and Breathing Trial Coordination, Delirium Assessment and Management, and Early Exercise and Progressive Mobility. Buoyed by growing intensivist interest and consistently improved patient outcomes, the Society of Critical Care Medicine (SCCM) launched the ICU Liberation Campaign, a quality improvement initiative that aims to refine and more widely disseminate the bundle, now called the ABCDEF Bundle Improvement Collaborative. The modified bundle acronym now stands for Assess, Prevent and Manage Pain; Both Spontaneous Awakening Trials and Spontaneous Breathing Trials; Choice of Analgesia and Sedation; Delirium: Assess, Prevent and Manage; Early Mobility and Exercise; and Family Engagement and Empowerment.

“The ICU patient has been held captive by us because of our mistaken ideas about care, so we use the term liberation to express the patient’s liberation from us,” explained Wesley Ely, MD, clinical leader of the collaborative and professor of medicine at Vanderbilt University Medical Center in Nashville, Tennessee, USA. “Inadvertently, ICU culture has become extremely depersonalizing and disease inducing. The patient’s dignity and self-worth is the point” of the collaborative, he said. Funded by the Gordon and Betty Moore Foundation, the last letter in the collaborative bundle was added in part at the request of Gordon Moore because of his own “harrowing ICU experience,” Ely explained.

“The family piece is the hardest to implement, but it solidifies the whole team,” said Diane Byrum, RN, manager of the ICU Liberation Campaign collaborative, and SCCM’s manager of quality implementation programs. “It goes beyond allowing the family to visit … you teach them what they can do to be a part of care.” She added, “It’s also the empowerment piece of the bundle—it allows the family to question what we’re doing because they know the care plan.”

“When it’s all put together, the sum is greater than the parts—there is exponential benefit,” Ely said. “Knowledge is power and the evidence is there. We must change—the new way has been seen to be better over and over again.”

In addition to seeking to minimize and eliminate post-ICU syndrome through lighter sedation and less time spent on mechanical ventilation, the collaborative has also set goals to reduce hospital and ICU length of stays, improve teamwork and collaboration among all ICU caregivers by adopting a shared language, validate compliance and improvement through an online data collection tool, and foster partnerships with other hospitals and healthcare systems nationwide that pursue similar goals.

Although the collaborative originally envisioned 20 hospitals participating from three regions—Southwest, Midwest and West Coast—an unexpected 98 hospitals applied to participate in the bundle improvement initiative. Sixty-eight were ultimately accepted, chosen to represent the range of ICUs nationwide, including community, academic, urban and rural hospitals of all sizes. Pediatric institutions asked to model their ICU improvement efforts after the adult collaborative, and eight children’s hospitals now comprise another arm of the initiative.

Collaborative participants began meeting this past summer, and retrospective data were gathered over the last two months of 2015. Prospective data will be gathered throughout 2016, with the goal that all participants will in turn further disseminate the bundle to hospitals in their regions. “Some participants are already doing some of these steps, while for others, it’s a complete change,” Byrum said. “When we begin to show them more patient improvements, that’s when we’ll really get buy-in.”

Ely supports healthy skepticism among the collaborative’s participants, however. “People have argued against some protocols, but that’s good,” he said. “Contradiction helps make it better.” Still, he said such a seismic shift in critical care is an “uphill battle” for many institutions attempting to break with ingrained practices, and it takes energy and effort to organize collaborative teams. “Medicine is so siloed, and we must de-silo all roles,” he said. As part of the paradigm shift, intensivist teams must also overcome the industry push to use drugs specifically administered to keep patients from remembering their ICU experience—“the benzo culture,” as he called it.

Community Hospital Collaborative
However, at Aultman Hospital in Canton, Ohio, USA, Ely is largely preaching to the choir. The independent community hospital collaborative participant already has considerable experience working on various aspects of the bundle.

“We have been measuring our ICU outcomes for the past several years, and we’ve learned that patients’ functional status—what happens to them when they go home—is just as important as their survival,” said Nihad Boutros, MD, Aultman’s medical director and physician champion for the bundle improvement collaborative. Aultman’s team also includes five other critical care/pulmonology intensivists, a clinical pharmacist, a critical care respiratory therapist, intensivist rounding nurses, a rapid response team and a dietitian, among others.

“The interdisciplinary approach has been a foundation for Aultman’s critical care for many years, and we are all very proud to be a part of this dynamic team,” said Amy Hiner, RN, a clinical nurse specialist and the hospital’s clinical nurse educator in critical care services.

“We have had a sedation protocol for 12 years,” Boutros said. “We’ve worked on interrupting and using lighter sedation, and on developing an objective scorecard tool to measure pain on a 1- to 5-point scale every 12 hours.” The scorecard also measures sedation, delirium and mobility. “We all discuss the scorecard on standing rounds,” Boutros said. “Once you’re aware of something, you will get better at it … it becomes your culture.” He added that the scorecard gives all team members the same communication tools, allowing for an objective assessment of patients’ needs and status.

Aultman’s critical care team has also been working on spontaneous awakening and breathing trials to reduce ICU delirium. “When the collaborative came along, we hoped we could be involved in reducing the whole constellation of psychiatric, neurocognitive and physical weakness problems that define post-ICU syndrome—and we hope to see a significant reduction in readmissions,” Boutros said.

“Our first goal is make all the component parts of the collaborative part of our culture,” Hiner said. “And our second goal is to be part of the next collaborative. It’s a continuing story that says, ‘This is the way we operate 24/7,’ and that’s the beauty of the collaboration.”

An Academic Approach
Another bundle improvement participant, the OU Medical Center’s Trauma ICU team at the University of Oklahoma Health Sciences Center in Oklahoma City, USA, is equally enthusiastic about the collaborative’s focus on team-based care. “Focusing on these different care elements integrates providers who all have a role,” said Pamela R. Roberts, MD, section chief of critical care medicine in the Department of Anesthesiology at the Health Sciences Center. “It gets a team of more interprofessionals at the bedside at the same time. It requires us to communicate more directly with each other—and it’s a different kind of communication than before.”

Those interprofessional members participate in daily patient rounds, sharing what they are doing and what they consider best next steps for each patient, rather than having the lead physician make all the decisions, Roberts explained. Like Aultman Hospital, OU already has experience with spontaneous awakening and breathing trials, including protocols for extubation readiness. Still, she added, “Some parts [of the bundle] are really different from what we formerly thought … We’ve had to change our understanding of ICU care.”

Nevertheless, Roberts said she is seeing more job satisfaction as team members such as respiratory therapists have become more engaged and more likely to speak up about care recommendations when they see that their input is valued and requested. She added that rounds are more efficient and actually take less time under the ABCDEF approach, and many nurses have told Roberts that they like the new methods better.

Trauma patients present unique challenges because of their pain medication and sedation needs, including the particular complexities of patients with traumatic brain injuries. Fortunately, there are several other trauma ICU teams participating in the collaborative who understand the OU trauma team’s challenges. Roberts said she hopes the teams can collaborate to devise pain and sedation scales, as well as daily delirium assessments that apply more specifically to the trauma department, coupled with assessments of how the trauma unit can limit the types of medication that most often contribute to delirium.

“The collaborative is designed to be 18 months long, but I predict we will continue after that … it will take longer than that to do all that we want to do with this,” Roberts said. She added that OU Medical Center plans to work on the family aspect of the bundle in its next phase of development, but the first goal is to ensure that all team members fully understand how their work integrates with others on the expanded ICU team.

“It’s interesting to see how different hospitals are in different stages of implementing this bundle,” Hiner said. “There are experts in different areas—but no one is an expert on all pieces—having the best of the best all working together is great.”

Ely knows that fully standardizing the collaborative’s protocols will be a long road. By his estimation, he has been working on the emerging letters of the ICU bundle at Vanderbilt for 20 years. Both he and the university are often cited as the genesis of the ABCDE initiative, but he countered, “The better view is that the medical field has grown up—the whole world has been working to reduce oversedation and improve ICU survival. Nobody owns it. We feel like we have many partners all over the world.”

Byrum said she thinks the application response to the ICU Liberation collaborative speaks volumes. “People know ICU processes are not working; there’s another and better way to do this ... this is the spark. We truly believe this is going to change the way we deliver care in the ICU.”