Organizational Characteristics Associated With ICU Liberation (ABCDEF) Bundle Implementation by Adult ICUs in Michigan

Juliana Barr, Amir A Ghaferi, Deena Kelly Costa, Haley K Hedlin, Victoria Y Ding, Corine Ross, Brenda T Pun, Sam R Watson, Steven M Asch, Juliana Barr, Amir A Ghaferi, Deena Kelly Costa, Haley K Hedlin, Victoria Y Ding, Corine Ross, Brenda T Pun, Sam R Watson, Steven M Asch

Abstract

The ICU Liberation (ABCDEF) Bundle can help to improve care and outcomes for ICU patients, but bundle implementation is far from universal. Understanding how ICU organizational characteristics influence bundle implementation could inform quality improvement efforts. We surveyed all hospitals in Michigan with adult ICUs to determine whether organizational characteristics were associated with bundle implementation and to determine the level of agreement between ICU physician and nurse leaders around ICU organizational characteristics and bundle implementation.

Design: We surveyed ICU physician and nurse leaders, assessing their safety culture, ICU team collaboration, and work environment. Using logistic and linear regression models, we compared these organizational characteristics to bundle element implementation, and also compared physician and nurse leaders' perceptions about organizational characteristics and bundle implementation.

Setting: All (n = 72) acute care hospitals with adult ICUs in Michigan.

Subjects: ICU physician and nurse leader pairs from each hospital's main ICU.

Interventions: We developed, pilot-tested, and deployed an electronic survey to all subjects over a 3 month period in 2016.

Results: Results from 73 surveys (28 physicians, 45 nurses, 60% hospital response rate) demonstrated significant variation in hospital and ICU size and type, organizational characteristics, and physician/nurse perceptions of ICU organization and bundle implementation. We found that a robust safety culture and collaborative work environment that uses checklists to facilitate team communication are strongly associated with bundle implementation. There is also a significant dose-response effect between safety culture, a collaborative work environment, and overall bundle implementation.

Conclusions: We identified several specific ICU practices that can facilitate ABCDEF Bundle implementation. Our results can be used to develop effective bundle implementation strategies that leverage safety culture, interprofessional collaboration, and routine checklist use in ICUs to improve bundle implementation and performance.

Keywords: ICU Liberation (ABCDEF) Bundle; checklists; critical care; intensive care units; patient safety; quality improvement.

Conflict of interest statement

Dr. Barr has received speaking honoraria from the Society of Critical Care Medicine and the Ohio Hospital Association and is a Scientific Advisor for Medasense Biometrics and Masimo. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Figures

Figure 1.
Figure 1.
The ICU Liberation (ABCDEF) Bundle.

References

    1. Barr J, Fraser GL, Puntillo K, et al. ; American College of Critical Care Medicine. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013; 41:263–306
    1. Devlin JW, Skrobik Y, Gélinas C, et al. Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Crit Care Med. 2018; 46:e825–e873
    1. Barnes-Daly MA, Phillips G, Ely EW. Improving hospital survival and reducing brain dysfunction at seven California community hospitals: Implementing PAD guidelines via the ABCDEF bundle in 6,064 patients. Crit Care Med. 2017; 45:171–178
    1. Pun BT, Balas MC, Barnes-Daly MA, et al. Caring for critically ill patients with the ABCDEF bundle: Results of the ICU liberation collaborative in over 15,000 adults. Crit Care Med. 2019; 47:3–14
    1. Society of Critical Care Medicine: ABCDEF Bundle. 2019. Available at: . Accessed June 21, 2019
    1. Hsieh SJ, Otusanya O, Gershengorn HB, et al. Staged implementation of awakening and breathing, coordination, delirium monitoring and management, and early mobilization bundle improves patient outcomes and reduces hospital costs. Crit Care Med. 2019; 47:885–893
    1. Boltey EM, Iwashyna TJ, Hyzy RC, et al. Ability to predict team members’ behaviors in ICU teams is associated with routine ABCDE implementation. J Crit Care. 2019; 51:192–197
    1. Costa DK, Valley TS, Miller MA, et al. ICU team composition and its association with ABCDE implementation in a quality collaborative. J Crit Care. 2018; 44:1–6
    1. Barnes-Daly MA, Pun BT, Harmon LA, et al. Improving health care for critically ill patients using an evidence-based collaborative approach to ABCDEF bundle dissemination and implementation. Worldviews Evid Based Nurs. 2018; 15:206–216
    1. Barnes-Daly MA, Barr J: Ch 11: Use of an interprofessional team model in the ICU to facilitate performance of the ICU Liberation Bundle. In: ICU Liberation. 2nd ed. Posa P, Singh J, Stollings J. Ch 11: Use of an interprofessional team model in the ICU to facilitate performance of the ICU Liberation Bundle. ICU Liberation. 2nd ed. 2020, Mount Prospect, IL: Society of Critical Care Medicine; 114–125
    1. Joint Commission International: Clinical Practice Guidelines: Closing the Gap Between Theory and Practice. 2016. Available at: . Accessed June 20, 2019
    1. Balas MC, Burke WJ, Gannon D, et al. Implementing the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle into everyday care: Opportunities, challenges, and lessons learned for implementing the ICU Pain, Agitation, and Delirium Guidelines. Crit Care Med. 2013; 41:S116–S127
    1. Balas MC, Pun BT, Pasero C, et al. Common challenges to effective ABCDEF bundle implementation: The ICU liberation campaign experience. Crit Care Nurse. 2019; 39:46–60
    1. Krein SL, Damschroder LJ, Kowalski CP, et al. The influence of organizational context on quality improvement and patient safety efforts in infection prevention: A multi-center qualitative study. Soc Sci Med. 2010; 71:1692–1701
    1. Miller MA, Govindan S, Watson SR, et al. ABCDE, but in that order? A cross-sectional survey of Michigan intensive care unit sedation, delirium, and early mobility practices. Ann Am Thorac Soc. 2015; 12:1066–1071
    1. Pronovost PJ, Berenholtz SM, Goeschel C, et al. Improving patient safety in intensive care units in Michigan. J Crit Care. 2008; 23:207–221
    1. Costa DK, White MR, Ginier E, et al. Identifying barriers to delivering the awakening and breathing coordination, delirium, and early exercise/mobility bundle to minimize adverse outcomes for mechanically ventilated patients: A systematic review. Chest. 2017; 152:304–311
    1. Cooke CR, Watkins TR, Kahn JM, et al. The effect of an intensive care unit staffing model on tidal volume in patients with acute lung injury. Crit Care. 2008; 12:R134.
    1. Kahn JM, Brake H, Steinberg KP. Intensivist physician staffing and the process of care in academic medical centres. Qual Saf Health Care. 2007; 16:329–333
    1. Pronovost PJ, Angus DC, Dorman T, et al. Physician staffing patterns and clinical outcomes in critically ill patients: A systematic review. JAMA. 2002; 288:2151–2162
    1. Wilcox ME, Chong CA, Niven DJ, et al. Do intensivist staffing patterns influence hospital mortality following ICU admission? A systematic review and meta-analyses. Crit Care Med. 2013; 41:2253–2274
    1. Checkley W, Martin GS, Brown SM, et al. ; United States Critical Illness and Injury Trials Group Critical Illness Outcomes Study Investigators. Structure, process, and annual ICU mortality across 69 centers: United States critical illness and injury trials group critical illness outcomes study. Crit Care Med. 2014; 42:344–356
    1. Sakr Y, Moreira CL, Rhodes A, et al. The impact of hospital and ICU organizational factors on outcome in critically ill patients: Results from the extended prevalence of infection in intensive care study. Crit Care Med. 2015; 43:519–526
    1. Penoyer DA. Nurse staffing and patient outcomes in critical care: A concise review. Crit Care Med. 2010; 38:1521–1528; quiz 1529
    1. Costa DK, Barg FK, Asch DA, et al. Facilitators of an interprofessional approach to care in medical and mixed medical/surgical ICUs: A multicenter qualitative study. Res Nurs Health. 2014; 37:326–335
    1. Rose L. Interprofessional collaboration in the ICU: How to define? Nurs Crit Care. 2011; 16:5–10
    1. Vazirani S, Hays RD, Shapiro MF, et al. Effect of a multidisciplinary intervention on communication and collaboration among physicians and nurses. Am J Crit Care. 2005; 14:71–77
    1. Pronovost P, Berenholtz S, Dorman T, et al. Improving communication in the ICU using daily goals. J Crit Care. 2003; 18:71–75
    1. Schwartz JM, Nelson KL, Saliski M, et al. The daily goals communication sheet: A simple and novel tool for improved communication and care. Jt Comm J Qual Patient Saf. 2008; 34:608–613, 561
    1. Flatow VH, Ibragimova N, Divino CM, et al. Quality outcomes in the surgical intensive care unit after electronic health record implementation. Appl Clin Inform. 2015; 6:611–618
    1. Richter JP, McAlearney AS. Targeted implementation of the Comprehensive Unit-Based Safety Program through an assessment of safety culture to minimize central line-associated bloodstream infections. Health Care Manage Rev. 2018; 43:42–49
    1. Romig M, Goeschel C, Pronovost P, et al. Integrating CUSP and TRIP to improve patient safety. Hosp Pract (1995). 2010; 38:114–121
    1. Confirmit AS: Survey Design and Analysis Software. 2019. Available at: . Accessed June 20, 2019
    1. MHA Keystone Center: About the MHA Keystone Center. 2019. Available at: . Accessed June 20, 2019
    1. Pronovost P, Goeschel C. Improving ICU care: It takes a team. Healthc Exec. 2005; 20:14–16, 18, 20 passim
    1. Costa DK, Kuza CC, Kahn JM. Differences between nurse and physician assessed ICU characteristics using a standardized survey. Int J Qual Health Care. 2015; 27:344–348
    1. Society of Critical Care Medicine: Critical Care Statistics. 2019. Available at: . Accessed June 20, 2019
    1. Michigan Department of Health and Human Services: Michigan Inpatient Database. 2019. Available at: . Accessed June 20, 2019
    1. Burns KE, Duffett M, Kho ME, et al. ; ACCADEMY Group. A guide for the design and conduct of self-administered surveys of clinicians. CMAJ. 2008; 179:245–252
    1. Luk EK, Rose L. Conducting a large survey of critical care nurses in Canada: Lessons learnt. Intensive Crit Care Nurs. 2011; 27:173–179
    1. McColl E, Jacoby A, Thomas L, et al. Design and use of questionnaires: A review of best practice applicable to surveys of health service staff and patients. Health Technol Assess. 2001; 5:1–256
    1. Agency for Health Care Research and Quality: Stories of Success: Using CUSP to Improve Patient Safety. 2019. Available at: . Accessed June 20, 2019
    1. Agency for Healthcare and Research Quality: About the National Quality Strategy. 2019. Available at: . Accessed June 20, 2019
    1. Christianson MK, Sutcliffe KM, Miller MA, et al. Becoming a high reliability organization. Crit Care. 2011; 15:314.
    1. Damschroder LJ, Aron DC, Keith RE, et al. Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implement Sci. 2009; 4:50.
    1. Farley DO, Damberg CL. Evaluation of the AHRQ patient safety initiative: Synthesis of findings. Health Serv Res. 2009; 44:756–776
    1. Sinuff T, Muscedere J, Adhikari NK, et al. ; KRITICAL Working Group, the Canadian Critical Care Trials Group, and the Canadian Critical Care Society. Knowledge translation interventions for critically ill patients: A systematic review*. Crit Care Med. 2013; 41:2627–2640
    1. Vogus TJ, Sutcliffe KM. The Safety Organizing Scale: Development and validation of a behavioral measure of safety culture in hospital nursing units. Med Care. 2007; 45:46–54
    1. Alsalem G, Bowie P, Morrison J. Assessing safety climate in acute hospital settings: A systematic review of the adequacy of the psychometric properties of survey measurement tools. BMC Health Serv Res. 2018; 18:353.
    1. Govindan S, Iwashyna TJ, Watson SR, et al. Issues of survivorship are rarely addressed during intensive care unit stays. Baseline results from a statewide quality improvement collaborative. Ann Am Thorac Soc. 2014; 11:587–591
    1. SurveyGizmo: Faster, Smarter, Affordable Survey Software. 2019. Available at: . Accessed June 20, 2019
    1. Microsoft: Microsoft Excel. 2019. Available at: . Accessed June 20, 2019
    1. Austin PC. Using the standardized difference to compare the prevalence of a binary variable between two groups in observational research. COMMUN STAT-SIMUL C. 2009; 38:1228–1234
    1. Cohen J. The effect size index: d. Statistical Power Analysis for the Behavioral Sciences. 1988Second EditionHillsdale, NJ, Lawrence Erlbaum Associates; 19–74
    1. Ziegler A. Generalized Estimating Equations. 2011, New York, NY: Springer
    1. Liang KY, Zeger SL. Longitudinal data analysis using generalized linear models. Biometrika. 1986; 73:13–22
    1. R Foundation: The R Project for Statistical Computing. 2019. Available at: . Accessed June 20, 2019
    1. Balas MC, Vasilevskis EE, Olsen KM, et al. Effectiveness and safety of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle. Crit Care Med. 2014; 42:1024–1036
    1. Dale CR, Kannas DA, Fan VS, et al. Improved analgesia, sedation, and delirium protocol associated with decreased duration of delirium and mechanical ventilation. Ann Am Thorac Soc. 2014; 11:367–374
    1. Sexton JB, Berenholtz SM, Goeschel CA, et al. Assessing and improving safety climate in a large cohort of intensive care units. Crit Care Med. 2011; 39:934–939
    1. Corser WD. The contemporary nurse-physician relationship: Insights from scholars outside the two professions. Nurs Outlook. 2000; 48:263–268
    1. Feng X, Bobay K, Weiss M. Patient safety culture in nursing: A dimensional concept analysis. J Adv Nurs. 2008; 63:310–319
    1. Aspden P, Corrigan JM, Julie Wolcott J, et al. Patient Safety: Achieving a New Standard for Care. Medicine (US) Committee on Data Standards for Patient Safety. Washington, DC, National Academies Press (US), 2004.
    1. Donovan AL, Aldrich JM, Gross AK, et al. ; University of California, San Francisco Critical Care Innovations Group. Interprofessional care and teamwork in the ICU. Crit Care Med. 2018; 46:980–990
    1. Landry MA, Lafrenaye S, Roy MC, Cyr C. A randomized, controlled trial of bedside versus conference-room case presentation in a pediatric intensive care unit. Pediatrics. 2007; 120:275–280
    1. Lane D, Ferri M, Lemaire J, et al. A systematic review of evidence-informed practices for patient care rounds in the ICU*. Crit Care Med. 2013; 41:2015–2029
    1. Lyons MN, Standley TD, Gupta AK. Quality improvement of doctors’ shift-change handover in neuro-critical care. Qual Saf Health Care. 2010; 19:e62.
    1. Thomas EJ, Sexton JB, Helmreich RL. Discrepant attitudes about teamwork among critical care nurses and physicians. Crit Care Med. 2003; 31:956–959
    1. Sfantou DF, Laliotis A, Patelarou AE, et al. Importance of leadership style towards quality of care measures in healthcare settings: A systematic review. Healthcare (Basel). 2017; 5:73
    1. Kristensen S, Christensen KB, Jaquet A, et al. Strengthening leadership as a catalyst for enhanced patient safety culture: A repeated cross-sectional experimental study. BMJ Open. 2016; 6:e010180
    1. Leung S, Gregg SR, Coopersmith CM, et al. ; Academic Leaders in Critical Care Medicine Task Force of the Society of the Critical Care Medicine. Critical care organizations: Business of critical care and value/performance building. Crit Care Med. 2018; 46:1–11
    1. Weled BJ, Adzhigirey LA, Hodgman TM, et al. ; Task Force on Models for Critical Care. Critical care delivery: The importance of process of care and ICU structure to improved outcomes: An update from the American College of Critical Care Medicine Task Force on Models of Critical Care. Crit Care Med. 2015; 43:1520–1525
    1. Boehm LM, Dietrich MS, Vasilevskis EE, et al. Perceptions of workload burden and adherence to ABCDE bundle among intensive care providers. Am J Crit Care. 2017; 26:e38–e47
    1. Boehm LM, Vasilevskis EE, Dietrich MS, et al. Organizational domains and variation in attitudes of intensive care providers toward the ABCDE bundle. Am J Crit Care. 2017; 26:e18–e28
    1. Pinto F, Biancofiore G. The ABCDE bundle: A survey of nurses knowledge and attitudes in the intensive care units of a national teaching hospital in Italy. Dimens Crit Care Nurs. 2016; 35:309–314
    1. Quality AfHRa. Toolkit for Using the AHRQ Quality Indicators. How to Improve Hospital Quality and Safety. 2016. Available at: . Accessed June 20, 2019

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