Category: Professional Posters
Purpose: The ABCDEF bundle (Assess, prevent, and manage pain; Both spontaneous awakening trials [SAT] and spontaneous breathing trials [SBT]; Choice of sedation and analgesia; Delirium assessment, prevention, and management; Early mobility and exercise; and Family communication and involvement) is a multidisciplinary and evidence-based approach to help apply the Pain, Agitation, and Delirium Guideline from the Society of Critical Care Medicine (SCCM). The purpose of this study is to track compliance with the bundle and to evaluate patient outcomes including intensive care unit (ICU) length of stay (LOS) and ventilator-free days in a neurological ICU (NICU).
Methods: The institutional review board approved this study. The training programs for the Confusion Assessment method for the ICU [CAM-ICU], the ABCDEF bundle, and the bundle checklist were provided by the ICU pharmacists from February to December 2018. CAM-ICU has been adopted to identify patients with delirium since April 2018. The ABCDEF bundle and its checklist have been performed since August 2018 and Jan 2019, respectively. The bundle was addressed each morning during rounds, and then documented on the checklist by the multidisciplinary team. Adult NICU patients (20 years old and above) with mechanical ventilation (MV) were eligiblefor the study. Patients who were extubated within less than 48 hours from MV were excluded. Data were collected retrospectively five months from January to May 2018 (pre-bundle) and prospectively from January to May 2019 (bundle). Demographic and clinical variables were collected from the first ICU day until the patient was designated to a non-ICU unit, was discharged or the patient died. The primary outcomes are ICU LOS and ventilator-free days. The secondary outcomes are in-hospital death and compliance with each bundle element, based on the documentation on the checklist. ABCDF compliance were measured on the days that the patient was intubated for a full 24 hours. E element compliance was measured from day five of MV. Comparisons were based on the chi-square test and the independent sample t-test.
Results: Data were collected on 104 patients in the study. Fifty-three percent were male with an age of 68±15 years in the bundle phase (n=77), and 59% were male with an age of 52±12 years in the pre-bundle phase (n=27). There was no significant difference between the two groups with regard to APACH II score (20.2±6.0 [bundle] vs. 18.0±6.2 [pre-bundle], p=0.09). After the ABCDEF bundle care, it was found that ICU LOS was shorter in the bundle phase (14.2±10.1) than the pre-bundle phase (18.3±18.7) with a decrease of 4 days in average, though not statistically significant (p=0.15). Ventilation-free days were similar in both phases (3.8±5.0 [bundle] vs. 4.1±6.0 [pre-bundle], p=0.80). Overall, patients who were in the bundle phase had a trend towards lower mortality rate than pre-bundle phase (58.4% vs. 66.7%, p=0.45). According to the documentation from the checklist, the average compliance with each element are 94.2% for A and C, 91.1% for SAT, 74.4% for SBT, 44.3% for E, and 69.2% for F. In the bundle phase, 100% of the patients received daily CAM-ICU assessment and the results are documented in the nurse system. However, the compliance with D element on the checklist is 88.8%.
Conclusion: In conclusion, we have shown that implementation of the multidisciplinary ABCDEF bundle for adult patients admitted to NICU with mechanical ventilation non-statistically reduction in ICU length of stay and in-hospital mortality. The key to success is improving health-care workers' compliance to the bundle. The comprehensive checklist is helpful for understanding which elements of the ABCDEF bundle require improvements.