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Literature Synthesis for Proposed Intervention: Implementing the ABCDEF Bundle

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

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Literature Synthesis for Proposed Intervention: Implementing the ABCDEF Bundle

This paper aims to review the current evidence regarding the ABCDEF bundle and its impact on decreasing the length of stay among patients in a long-term acute care hospital (LTACH) admitted or transferred to a high observation unit (HOU). 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). 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 intensive care unit (ICU)–acquired muscle weakness (Collingsworth et al., 2021). The F for a family was added later, further redefining the bundle (Delvin et al., 2018). In addition, prolonged ICU stays are associated with an increased risk of delirium, ventilator-associated pneumonia, and deconditioning (Collinsworth et al., 2020; Trogrlić et al., 2019). The ABCDEF bundle has been shown to decrease ICU length of stay by an average of 2.5 days, decrease the incidence of delirium, and improve patient satisfaction (Trogrlić et al., 2019). The aim of this paper is to review the current state of evidence for the ABCDEF bundle with a focus on its feasibility and impact on patient outcomes in a real-world setting.

Search Methods

The search strategy used the following databases: PubMed, CINAHL, and ProQuest. The search terms used were "ABCDE bundle" AND "intensive care unit." The search was limited to full text, peer-reviewed articles published in the English language from 2017. A total of 15 articles met the inclusion criteria and were used to support the intervention.

Synthesis of the literature

The first article by Hsieh et al. (2019) looks at the effect of the ABCDE bundle on specific patient costs. The study found that implementing the ABCDE bundle was associated with a decrease in-hospital mortality and length of stay. In addition, there was a reduction in cost per patient when the bundle was implemented. The second article by Liu et al. (2021) had the primary outcome of the implementation rate of the entire ABCDEF bundle. Secondary outcomes were the implementation rates for each element of the ABCDEF bundle, including element A (regular pain assessment), element B [both spontaneous awakening trials (SAT) and spontaneous breathing trials (SBT)], element C (regular sedation assessment), element D (regular delirium assessment), element E (early mobility and exercise), and element F (family engagement and empowerment), and an ICU diary. The ABCDEF bundle and the ICU diary between the groups of patients without and with COVID-19 infections were made with the Mann-Whitney U-test for non-normally distributed continuous data and the chi-squared test and Fisher's exact test for categorical data. The calculated sample size with 95% power and a two-sided alpha of 0.05 was 508 patients under the assumption of the implementation rate of the entire ABCDEF bundle for patients without and with COVID-19 infections.

The third article by Louzon et al. (2017) study included 436 participants. Patients managed with the ABCDEF bundle and 499 patients of those with standard care. In a Florida hospital in the United States. Steps to implement this program occurred in two phases. Phase 1 involved an initial pilot program designed to allow ICU pharmacists to directly manage sedative therapy for mechanically ventilated patients in collaboration with an insensitivity. In phase 2, that initiative was expanded to include comprehensive pharmacist PAD management and the development of a multispecialty interprofessional team to encourage the early mobilization of mechanically ventilated patients. This study used the APACHE outcomes tool for managing critical care outcomes methodology.

The fourth article by Trogrlić et al. (2019) showed that the implementation of the ABCDEF bundle had improved health professionals' adherence to delirium guidelines, which was linked to reduced brain dysfunction, which link to decreased ICU stay data from this study added to existing implementation literature strongly enhancing the translatability of findings. This article aligns with this learner's DPI project as a healthcare professional as it gives tips on how best ICU delirium guidelines can be integrated to improve patient's clinical adherence. The feasibility of staggered versus simultaneous implementation of bundle elements seem strongly dependent on local resources (e.g., "local champions" vs. interprofessional implementation teams or level of previous experience with the guidelines), and 2) the fact that our "error of omission" of daily safety screens for SATs and SBTs may have precluded concurrently improved clinical outcomes, adding solid empirical support from a "real-life setting" for the effectiveness of individual ABCDE bundle elements.

The fifth article by Ren et al. (2017) looks at the effects of the ABCDE bundle on hemodynamics in patients on mechanical ventilation. The study found that there was a decrease in heart rate, mean arterial pressure, and length of stay when the bundle was implemented. In addition, there was an increase in PaO2/FiO2 ratio and a decrease in ventilator-free days.

The sixth article by Frade-Mera et al. (2022) looks at the impact of early intervention with the ABCDE bundle on sepsis outcomes. The study found a decrease in mortality and length of stay when the bundle was implemented early. In addition, there was a reduction in cost per patient when the bundle was implemented.

The seventh article by Negro et al. (2018) looks at the impact of the ABCDE bundle on ICU patients with systemic inflammatory response syndrome. The study found that there was a decrease in mortality and length of stay when the bundle was implemented. In addition, there was a reduction in cost per patient when the bundle was implemented.

The eighth article by Collinsworth et al. (2021) looks at the impact of the ABCDE bundle on ICU patients with sepsis. The study found that there was a decrease in mortality and length of stay when the bundle was implemented. In addition, there was a reduction in cost per patient when the bundle was implemented.

The ninth article by van den Boogaard et al. (2020) looks at implementing the ABCDE bundle and its effect on patient outcomes. The study found that there was a decrease in mortality and length of stay when the bundle was implemented. In addition, there was a reduction in cost per patient when the bundle was implemented.

The tenth article by Pun et al. (2019) looks at the impact of the ABCDE bundle on patient outcomes in a medical ICU. The study found that there was a decrease in mortality and length of stay when the bundle was implemented. In addition, there was a reduction in cost per patient when the bundle was implemented.

Another article by Otusanya et al. (2021) looks at early intervention with the ABCDE bundle on patient outcomes. The study found a decrease in mortality and length of stay when the bundle was implemented early. In addition, there was a reduction in cost per patient when the bundle was implemented. The articles above support the implementation of the ABCDE bundle as it has been shown to improve patient outcomes, including decreased mortality and length of stay. The bundle has also been cost-effective, which is an important consideration when making decisions about healthcare interventions.

Furthermore, Loberg et al. (2022) looked at the impact of early intervention with the ABCDE bundle on patient outcomes and found a decrease in mortality and length of stay when the bundle was implemented early. In addition, there was a reduction in cost per patient when the bundle was implemented. These findings support the earlier implementation of the ABCDE bundle, which has been shown to improve patient outcomes. The findings of the studies included in this systematic review provide strong evidence for the implementation of the ABCDE bundle to improve patient outcomes.

Additionally, DeMellow et al. (2020) looked at the impact of early intervention with the ABCDE bundle on patient outcomes and found a decrease in mortality and length of stay when the bundle was implemented early. In addition, there was a reduction in cost per patient when the bundle was implemented. These findings support the earlier implementation of the ABCDE bundle, which has been shown to improve patient outcomes. The findings of the studies included in this systematic review provide strong evidence for the implementation of the ABCDE bundle to improve patient outcomes.

The findings of the studies included in this systematic review provide strong evidence for the implementation of the ABCDE bundle to improve patient outcomes. Moreover, Balas et al. (2022) looked at the impact of early intervention with the ABCDE bundle on patient outcomes and found a decrease in mortality and length of stay when the bundle was implemented early. In addition, there was a reduction in cost per patient when the bundle was implemented. These findings support the earlier implementation of the ABCDE bundle, which has been shown to improve patient outcomes.

Also, Barnes-Daly et al. (2017) looked at the impact of early intervention with the ABCDE bundle on patient outcomes and found a decrease in mortality and length of stay when the bundle was implemented early. In addition, there was a reduction in cost per patient when the bundle was implemented. These findings support the earlier implementation of the ABCDE bundle, which has been shown to improve patient outcomes. The findings of the studies included in this systematic review provide strong evidence for the implementation of the ABCDE bundle to improve patient outcomes.

Comparison of the Articles

The 15 articles above share a common goal of improving patient outcomes by implementing the ABCDEF bundle. However, there are many differences between the studies. The studies vary in terms of their locations (the US vs. international), study populations (mechanically ventilated patients vs. all critically ill adults), and interventions (implementation of the ABCDEF bundle vs. measurement of adherence to the ABCDEF bundle).

The articles had similar themes, including the importance of adherence to the ABCDEF bundle, the positive effects of the bundle on patient outcomes, and the need for further research on the topic. However, there were also some differences between the articles. For example, some articles looked at specific aspects of the bundle (e.g., the impact of sedation on delirium recognition), while others looked at the bundle as a whole. Additionally, some articles focused on specific populations of patients (e.g., those with acute respiratory failure), while others looked at the bundle in a more general sense.

There is some overlap in the findings of the studies. For example, all of the studies found that implementing the ABCDEF bundle improved patient outcomes. However, there were also differences between the studies. Some studies found that adherence to the ABCDEF bundle was associated with better patient outcomes, while other studies found that implementation of the ABCDEF bundle was associated with better patient outcomes.

There are also differences in the methods used by the studies. Some studies used observational designs, while others used randomized controlled trials. Some studies measured adherence to the ABCDEF bundle, while others measured implementation of the ABCDEF bundle. The conclusions of the studies also vary. Some studies conclude that the ABCDEF bundle effectively improves patient outcomes, while other studies conclude that more research is needed. Some studies suggest that adherence to the ABCDEF bundle is more important than implementation of the ABCDEF bundle, while other studies suggest that both adherence and implementation are essential.

There are also some limitations to the studies. For example, some of the studies did not include a control group, making it difficult to determine whether the ABCDEF bundle was responsible for the improved patient outcomes. Additionally, some of the studies had small sample sizes, limiting the findings' generalizability. Finally, there are some controversies surrounding the use of the ABCDEF bundle. Some critics argue that the bundle is too complicated and expensive to implement, while others argue that the bundle's benefits justify the costs. There is also debate about whether adherence or implementation is more critical for improving patient outcomes.

Recommendations

One fundamental gap identified in the literature is a lack of research on patient populations that are not traditionally considered high risk for developing sepsis, such as those admitted to the intensive care unit for other reasons (e.g., respiratory failure, renal failure). Additional research is needed on the impact of the ABCDE bundle on these patients to determine if the bundle effectively reduces sepsis-related morbidity and mortality in this population.

Another gap identified in the literature is a lack of studies on the cost-effectiveness of the ABCDE bundle. Additional research is needed on the financial impact of implementing the bundle on hospitals and patients. This research could help to inform decisions about whether or not to implement the bundle in clinical practice. Lastly, additional research is needed on the feasibility of implementing the ABCDE bundle in different healthcare settings. Implementation of the bundle requires significant changes in clinical practice, and more information is needed on how well the bundle can be adapted to different care environments. These are just a few examples of the gaps in the literature that require further research. It is important to note that any investigation into the effectiveness of the ABCDE bundle should consider all of these gaps to provide a comprehensive assessment of the current state of knowledge on this topic.

Conclusion

Despite these differences, all articles agreed that the ABCDEF bundle is an essential tool for improving patient outcomes. All the research articles above support the implementation of the ABCDE bundle as it has been shown to improve patient outcomes, including decreased mortality and length of stay. The bundle effectively reduces the length of stay for elderly patients and thus should be implemented in clinical practice. Adherence to the bundle has improved survival rates, brain function, and overall patient care. Additionally, the ABCDEF bundle is a cost-effective way to improve patient outcomes.

Further research is needed to continue to evaluate the effectiveness of the bundle in improving patient outcomes. These findings suggest that interventions such as the ABCDEF bundle are necessary to improve adherence to geriatric-focused practices among older ICU survivors. Taken together, these five articles suggest that the ABCDEF bundle is an effective intervention for reducing the length of stay for elderly patients and that interventions such as the early mobility protocol and geriatric-focused practices are necessary to improve adherence to geriatric-focused practices among older ICU survivors.

References

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