this assignment is referring the ABCDEF bundle - the template pages is attached - add info of the ABCDEF bundle in a long-term acute hospital. PICOT: will implementing the ABCDEF bundle decrease le

Implementation Into Practice: The ABCDEF Bundle

Cathy Jones

Doctor of Nursing Practice Grand Canyon University

DNP-820A: Translational Research and Evidence-Based Practice

Dr. Carolyn Boiman

March 16, 2022

Implementation Into Practice: The ABCDEF Bundle

In 2013 the Society of Critical Care Medicine initiated the ICU Liberation campaign from the PAD Clinical Practice Guideline. The guideline was updated in 2018, now known as the ICU Liberation-ABCDEF bundle. This learner's DPI Project aims to decrease the length of stay in a long-term acute care hospital of adult patients in the high observation unit implementing the ABCDEF bundle. The ABCDE (Awakening and Breathing Coordination, Delirium Monitoring and Management, and Early Exercise and Mobility) bundle, a validated evidence-based protocol, was initially created to improve outcomes of patients in the intensive care unit (ICU). The bundle consists of spontaneous awakening trials (SATs) to decrease the use of sedation, spontaneous breathing trials (SBTs) to wean patients off mechanical ventilation faster, coordination of awakening and breathing trials to maximize benefits of SATs and SBTs, delirium screening and treatment, and early progressive mobility to decrease ICU–acquired muscle weakness (Collingsworth et al., 2021). The F for a family was added later, further redefining the bundle (Delvin et al., 2018). Individually these interventions have been associated with reductions in incidence and duration of delirium and improved patient outcomes such as shorter duration of mechanical ventilation, shorter ICU and hospital length of stay, improved functional outcomes and improved survival (Collingsworth et al., 2021). Pain may be a contributing factor in up to 50% of cases of agitation or delirium, a significant contributor in more extended hospitalization (Sosnowski et al., 2021). During the last decade, researchers have produced strong evidence demonstrating the hazards of delirium and the benefits of particular interventions, such as the individual components of the ABCDE bundle, in preventing and mediating this condition.

The Extent to Which the Practice is Being Implemented

Several studies across the country published their findings on its implementation. Pun et al. (2019) published the results of its study, which included over 15,000 adults that showed significant and clinically meaningful outcomes, including survival, mechanical ventilation use, coma, delirium, restraint-free care, reduction in ICU admissions, and alterations in post-ICU discharge destinations. A study by Sosnowski et al. (2021) assessed the implementation of the ABCDEF bundle in 5 ICUs in the United States. A study by Hsieh et al. (2019) demonstrates that the complex ABCDE bundle can be successfully implemented into routine care showing the addition of early mobilization and bundle coordination to an established targeted sedation and delirium management program led to substantial reductions in mechanical ventilation duration, length of stay, and hospital cost, liberated patients from restraints, and reduced iatrogenic complications. A meta-analysis was conducted by Zhang et al. (2021) of 26,384 participants evaluating the impact of the bundle interventions on ICU delirium prevalence, duration, and other adverse outcomes. More recently, in a study conducted in Spain, Frade-Mera et al. (2022) identified patients who had shorter stays in ICUs with bundle protocols and fewer days of IMV in ICUs with delirium and mobilization bundle components patients had shorter ICU stays days on mechanical ventilation.

Evaluation of Possible Barriers

Unfortunately, the ABCDEF bundle is not widely implemented in practice despite the bundle's significant clinical outcomes. There are several potential barriers to the implementation of the ABCDEF bundle. The first barrier is the lack of familiarity with the guideline among healthcare providers. Many providers may be unaware of the guideline or its recommendations. A second barrier is that many healthcare facilities do not have the resources to implement all six interventions of the ABCDEF bundle. Resources needed to implement the ABCDEF bundle effectively include personnel (e.g., nurses, pharmacists, physical therapists), equipment (e.g., patient monitors), and funding for additional staff and equipment (AHRQ, 2017). A third barrier is that some healthcare facilities may not have standardized protocols for implementing the ABCDEF bundle. Without standardized protocols, care may be inconsistent across different units within a facility. Last, the culture of a healthcare facility can also be a barrier to implementing the ABCDEF bundle. The culture of a healthcare facility is defined by its values and norms, and it can be challenging to change the culture of a healthcare facility.

Ways to Overcome the Barriers

There are several ways to overcome the barriers to implementing the ABCDEF bundle. The first way is to increase awareness of the guideline among healthcare providers. Many providers may not be aware of the guideline or its recommendations. Educational programs can increase awareness of the guideline among healthcare providers. A second way is to provide resources (e.g., personnel, equipment, funding) to healthcare facilities to implement all six interventions of the ABCDEF bundle (Loberg et al., 2022). Many healthcare facilities do not have the resources to implement all six interventions of the ABCDEF bundle. Resources needed to implement the ABCDEF bundle effectively include personnel (e.g., nurses, pharmacists, physical therapists), equipment (e.g., patient monitors), and funding for additional staff and equipment. A third way is to develop standardized protocols for implementing the ABCDEF bundle (Loberg et al., 2022). Without standardized protocols, care may be inconsistent across different units within a facility. Standardized protocols can help ensure that care is delivered consistently across different units within a facility. Last, the culture of a healthcare facility can be changed by introducing new values and norms that support the implementation of the ABCDEF bundle. The culture of a healthcare facility can be challenging to change, but it is not impossible (AHRQ, 2017).

Discussion of the Resources Available on the Selected Site

The AHRQ website provides several resources to help healthcare facilities implement the ABCDEF bundle. The website includes an evidence report, clinical practice guidelines, and toolkits for healthcare providers. The evidence report summarizes the evidence supporting the use of the ABCDEF bundle. The clinical practice guideline provides specific recommendations for implementing the ABCDEF bundle (AHRQ, 2017a). The toolkits provide tools and resources that healthcare providers can use to implement the ABCDEF bundle in their facility. The AHRQ website also includes a database of quality improvement programs that healthcare facilities can use to improve the quality of care. The AHRQ website is a valuable resource for healthcare providers looking to improve the quality of care (AHRQ, 2017a).

Conclusion

There is evidence that the ABCDEF bundle effectively reduces pain, agitation, and delirium in elderly patients. However, the bundle is not widely implemented in practice. There are several ways to overcome the barriers to implementing the ABCDEF bundle, including increasing awareness, introducing standardized protocols, and increasing funding. The AHRQ website provides resources to help hospitals overcome the barriers to implementing the ABCDEF bundle.

References

Agency for Healthcare Research and Quality. [AHRQ]. (2017). Evidence behind Pain, Agitation, and Delirium: Assessments and Sedation Management: Facilitator Guide. Ahrq.gov. https://www.ahrq.gov/hai/tools/mvp/modules/technical/pain-mgmt-slides.html.

Agency for Healthcare Research and Quality. [AHRQ]. (2017a). Evidence behind Pain, Agitation, and Delirium: Assessments and Sedation Management: Slide Presentation: Overview. https://www.ahrq.gov/hai/tools/mvp/modules/technical/pain-mgmt-slides.html

Collinsworth, A. W., Brown, R., Cole, L., Jungeblut, C., Kouznetsova, M., Qiu, T., Richter, K. M., Smith, S., & Masica, A. L. (2021). Implementation and Routinization of the ABCDE Bundle: A Mixed Methods Evaluation. Dimensions of Critical Care Nursing : DCCN, 40(6), 333–344. https://doi-org.lopes.idm.oclc.org/10.1097/DCC.0000000000000495

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Frade-Mera, M. J., Arias-Rivera, S., Zaragoza-García, I., Martí, J. D., Gallart, E., San José-Arribas, A., Velasco-Sanz, T. R., Blazquez-Martínez, E., & Raurell-Torredà, M. (2022). The impact of ABCDE bundle implementation on patient outcomes: A nationwide cohort study. Nursing in Critical Care. https://doi-org.lopes.idm.oclc.org/10.1111/nicc.12740

Hsieh, S. J., Otusanya, O., Gershengorn, H. B., Hope, A. A., Dayton, C., Levi, D., Garcia, M., Prince, D., Mills, M., Fein, D., Colman, S., & Gong, M. N. (2019). Staged implementation of awakening and breathing, coordination, delirium monitoring and management, and early mobilization bundle improves patient outcomes and reduces hospital costs. Critical Care Medicine, 47(7), 885–893. https://doi-org.lopes.idm.oclc.org/10.1097/CCM.0000000000003765

Loberg, R., Smallheer, B., & Thompson, J. (2022). A Quality Improvement Initiative to Evaluate the Effectiveness of the ABCDEF Bundle on Sepsis Outcomes. Critical Care Nursing Quarterly, 45(1), 42-53. https://doi.org/10.1097/cnq.0000000000000387.

Pun, B. T., Balas, M. C., Barnes-Daly, M. A., Thompson, J. L., Aldrich, J. M., Barr, J., Byrum, D., Carson, S. S., Devlin, J. W., Engel, H. J., Esbrook, C. L., Hargett, K. D., Harmon, L., Hielsberg, C., Jackson, J. C., Kelly, T. L., Kumar, V., Millner, L., Morse, A., … Ely, E. W. (2018). Caring for critically ill patients with the ABCDEF bundle: Results of the ICU liberation collaborative in Over 15,000 adults. Critical Care Medicine. https://doi-org.lopes.idm.oclc.org/10.1097/CCM.0000000000003482 https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=edsovi&AN=edsovi.10.1097.CCM.0000000000003482&site=eds-live&scope=site&custid=s8333196&groupid=main&profile=eds1

Sosnowski, K., Mitchell, M., Cooke, M., White, H., Morrison, L., & Lin, F. (2021). Effectiveness of the ABCDEF bundle on delirium, functional outcomes and quality of life in intensive care patients: a study protocol for a randomized controlled trial with embedded process evaluation. BMJ Open, 11(7), e044814. https://doi.org/10.1136/bmjopen-2020-044814

Zhang, S., Han, Y., Xiao, Q., Li, H., & Wu, Y. (2021). Effectiveness of Bundle Interventions on ICU Delirium: A Meta-Analysis. Critical Care Medicine, 49(2), 335–346. https://doi-org.lopes.idm.oclc.org/10.1097/CCM.0000000000004773