Implementation of the ABCDE Bundle: Results from a Real-World, Pragmatic Study Design. Andrew Masica, MD, MSCI Chief Clinical Effectiveness Officer

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1 Implementation of the ABCDE Bundle: Results from a Real-World, Pragmatic Study Design Andrew Masica, MD, MSCI Chief Clinical Effectiveness Officer 0

2 Gap Between Knowledge and Delivery Translational Roadmap Daugherty, JAMA 2008

3 ICU Delirium ( Ever vs. Never ) Increased ICU length of stay (8 vs 5 days) Increased hospital length of stay (21 vs 11 days) Increased time on ventilator (9 vs 4 days) Higher ICU costs ($22,000 vs $13,000) Higher ICU mortality (19.7% vs 10.3%) Higher hospital mortality (26.7% vs 21.4%) 3-fold increased risk of death at 6 months Building evidence as a risk factor for long-term cognitive impairment Ely, et al. ICM2001; 27, Ely, et al, JAMA 2004; 291: Lin, SM CCM 2004; 32: Milbrandt E, et al, Crit Care Med 2004; 32: Ouimet, et al, ICM 2007: 33:

4 The ABCDE Bundle Morandi A et al. Curr Opin Crit Care,2011;17:43-9 3

5 Baylor Scott & White Health (BSWH) Integrated delivery system with more than 500 patient care sites including 43 hospitals in North and Central Texas 5.3 million patient encounters annually 34,000 employees 6,000 affiliated physicians Scott & White Health Plan $8.3 billion in total assets $5.8 billion in total net operating revenue 4

6 ABCDE Bundle Implementation Tactics Adoption Program Component Time to Completion Activate Nurse/ Physician Champions and secure clinical staff conceptual buy-in Assess current state (workflow, performance) Development of supportive EHR Documentation and order set with incorporation into production (live use) environment Training Sessions (staged at hospitals with multiple ICUs): a. Train the trainer (with outside consultants) b. Frontline staff training (2-hour session) Use of daily rounding tool Standardized Performance Reporting (hospital and unit levels) Optimization/EHR refinement/standing meetings Accountability as a system critical care goal 1-3 months (based on hospital size) 1-month 9-12 months 4-6 month cycle to launch each unit; multiple reinforcement sessions required months 4 months after completion of EHR workflow tools Ongoing 3 months after standardized reporting 5

7 Quasi-Experimental Study Design Intervention Groups Design Characteristics Basic Implementation Program Access to EHR modifications Access to standardized reports Enhanced Implementation Program Access to EHR modifications Access to standardized reports Engagement of site champions Participation in content development Supplemental training 3 hospitals in each group Matched site traits wherever able Programs operated concurrently Randomization not feasible Outcomes analyses via time series 6

8 Order Set 7

9 Critical Care Flowsheet 8

10 Frontline Staff Training ICU Nurses, respiratory therapists, physical/occupational therapists Brief lecture about the ABCDE Bundle elements Role playing regarding delirium identification with case studies Use of the new electronic documentation tools Discussion of adoption barriers and troubleshoooting strategies Incorporation of the bundle into routine clinical care Teachback of key concepts To allow scale up: Session was modified to become a train the trainer program Development of e-learning modules 9

11 Standardized Performance Reporting Eligibility for Report: Vent 24 hours Vent 2 weeks Specific neuro. diagnoses excluded Based on admin. data 10

12 Real-Time Measure-Vention 11

13 Accountability Eligible Population: ICU patients with acute respiratory failure requiring mechanical ventilation for 24 hrs. Denominator based on the # of observations for which the patient is eligible Observations after > 14 days on mechanical ventilation excluded Performance Targets: A Daily Awakening Trial: 60-70% (1 point); 71-80% (2 points), above 80% (3 points) B Breathing Trials: 60-70% (1 point); 71-80% (2 points); above 80% (3 points) D Delirium Screening: 70-80% (1 point), 81-90% (2 points); above 90% (3 points) E 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) 12

14 ABCDE-Composite Bundle Adherence Trends 13

15 Individual Bundle Element Adherence Trends 14

16 Improvement in ABCDE Practice Adherence: Pre- vs. Post-Implementation Program % Pre n=290 Post n=394 Basic Difference p-value Pre n=942 Post n=1183 Enhanced Difference p-value SAT < <.0001 SBT < <.0001 CAM-ICU < <.0001 Early Mobility < <.0001 ABCDE Bundle < <.0001 Sites with fewer total # of ICUs and consistency in attending critical care physicians demonstrated faster practice uptake. Prior success with other QI initiatives was also a strong predictor of adoption Uptake in the enhanced group strongly influenced by results at the 1000 bed tertiary hospital 15

17 Bundle Impact on Patient Outcomes: Preliminary Data Patients with Bundle Adherence Rate 60% Spent less time on the ventilator (-.32 days; 95%CI: -0.55, -0.08) Observed delirium incidence increased (OR = 1.25; 95%CI: ) Attributed to better detection and unmasking of hidden delirium Had fewer total days with coma or delirium (45%; 95%CI: ) Were more likely to be mobilized out of bed (OR = 2.05, 95%CI: ) Were more likely to be discharged home (OR = 1.22; 95%CI: ) Had reduced risk of inpatient mortality (OR = 0.43; 95%CI: ) 16

18 Implementation Costs (System Level) Key Personnel FTE Costs represent initial 1-year deployment period *Estimated Average Yearly Salary Annual cost for maintenance phase decreases to $30-40K range (data management, reports, training) *United States Department of Labor, Bureau of Labor Statistics Salary Cost Project Lead.10 $187,200 $18,720 Project Manager.40 $82,790 $33,116 Physician Champions.20 $187,200 $37,440 Nurse Champions.20 $65,470 $13,094 Data Analyst.50 $77,080 $38,540 Information Services.25 $100,000 $25,000 Total $165K 17

19 Lessons Learned Staff training should extend beyond a 15-minute in service as the ABCDE bundle involves a cultural change. Delirium management by physicians needs to keep pace with improved recognition by nurses. Observed variability in bundle uptake within and among hospitals-local factors (particularly QI acumen) strongly influence adoption. Person-to-person propagation and clear lines of accountability are crucial to adoption of the ABCDE bundle (similar to adoption of other innovations). Focusing resources on EHR modification (placing this phase as early as possible in the implementation program sequence) appears to be a higher-yield practice uptake approach. 18

20 Acknowledgements/Funding Support Grant R18-HS from the Agency for Healthcare Research and Quality (AHRQ). The findings and conclusions in this program are those of the authors, who are responsible for its content, and do not necessarily represent the views of AHRQ. No other disclosures 19

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