Perceptions of Workload Burden and Adherence to ABCDE Bundle Among Intensive Care Providers

Antecedents and Outcomes of Physician Coworker Conflict: A Differential Occupational Model for Health Care Managers

OBJECTIVES

Interpersonal conflict between physicians and their coworkers hinders health care organizations today on an unprecedented scale. Most research on physician conflict has been restricted to 2 occupational groups, nurses and administrators. Yet as health care delivery becomes more complex and interdependent, physician interpersonal conflict impacts all occupational groups. Thus, we seek to provide health care managers with specific guidance about how they might eliminate negative effects of physician-related interpersonal conflict for each occupation.

METHODS

We examined antecedents and outcomes of physician conflict across 4 occupational groups (office clerical and support staff, professional and technical, nursing, and managerial) in a survey of 1451 US health care employees. Using Multigroup Structural Equations Modeling (MSEM) analysis we estimated each relationship in our model across the 4 occupational groups.

RESULTS

We found that workload, perceived HR climate and patient-related incentives predicted physician conflict, and that physician conflict related to burnout, intention to turn over and psychological safety. Most notably, these antecedents and outcomes varied meaningfully across occupational groups.

CONCLUSIONS

These observed differential effects in our results suggest that managers should carefully consider the needs of different occupational groups separately when designing and implementing interventions to prevent and ameliorate physician conflict. In short, the antecedents and outcomes of physician conflict are different for office/clerical, nurses, professional/technical employees, and management groups and therefore require different solutions. In short, it behooves health care organizations to avoid a one size fits all approach to improving workplace relationships.

Analgosedation and delirium practices in critically ill patients in the Pan-American and Iberian setting, and factors associated with oversedation after the COVID-19 pandemic: Results from the PANDEMIC study

Oversedation has adverse effects on critically ill patients. The Analgosedation and Delirium Committee of the FEPIMCTI (Pan-American and Iberian Federation of Critical Care Medicine and Intensive Care) conducted a cross-sectional study through a survey addressed to ICU physicians: PANDEMIC (Pan-American and Iberian Study on the Management of Analgosedation and Delirium in Critical Care [fepImCti]). HYPOTHESIS: Worsening of these practices in the course of the pandemic and that continued afterwards, with further oversedation. OBJECTIVES: Perception of analgosedation and delirium practices in Pan-American and Iberian ICUs before, during and after the COVID-19 pandemic, and factors associated with persistent oversedation after the pandemic. Of the 1008 respondents, 25% perceived oversedation after the pandemic (95%CI 22.4-27.8). This perception was higher in South America (35.8%, P < .001). Main risk factor: habit acquired during the pandemic (adjusted OR [aOR] 3.16, 95%CI 2.24-4.45, P < .001). Main protective factor: delirium monitoring before the pandemic (aOR 0.70, 95%CI 0.50-0.98, P = .038). The factors identified in this study provide a basis for targeting future interventions.

Barriers to nurse-led delirium management in intensive care units: an integrative systematic review using COM-B model

BACKGROUND

Development of effective guideline for delirium management is still seeking nowadays. As nurses are in the first confrontation line for delirium, their prospective in identifying barriers are essential in developing integrated strategies and clinical guidelines.

OBJECTIVE

To explore the barriers focusing on intensive care unit (ICU) nurses' point of views to provide an evidence-based support for effective nurse-led delirium management in ICU settings.

METHODS

Whittemore and Knafl framework was recruited to build up this integrative review. PRISMA guidelines were followed to search about barriers of nurse-led delirium management. Articles published up to June 2024 in five databases; Web of Science, Scopus, PubMed, CINAHL and EMBASE using related keywords were involved. Mixed Methods Appraisal Tool (MMAT) was used to evaluate the quality of articles included in this review and then reported nurse-led delirium barriers were mapped according to COM-B model.

RESULTS

Twenty-three articles out of 1,020 research articles were included in this review after carefully checked according to the exclusion and inclusion criteria. based on MMAT, 7 articles achieved 100%, 11 articles were achieved 80%, and 5 articles achieved 60%. Nurses' knowledge deficit is the most common psychological capability barriers of nurse-led delirium management, while complexity of delirium screening tools was found to be a physical capability barriers. High workload, lack of staff, lack of time, lack of documentation and lack/ shortage of guidelines were barriers mapped to physical opportunity, while communication barriers in particular patient's intubation and sedation were mapped to social opportunity barriers. Motivation was represented by addressing delirium as a major problem, self-confidence, psychological support and considering nurse's views.

CONCLUSIONS

Nurse's knowledge deficit, complexity of delirium screening tools, high workload, lack of time, lack of documentation, lack/ shortage of guideline, and impaired communication were barriers of nurse led delirium management. This study is promising in ease of application in clinical practice since delirium barriers in ICU settings were well-presented in a COM-B framework that may facilitate therapeutic strategies and related decision making.

Creating a Culture of an Awake and Walking Intensive Care Unit: In-Hospital Strategies to Mitigate Post-Intensive Care Syndrome

The ABCDEF bundle and Awake and Walking intensive care unit (ICU) approach aim to prevent the long-term consequences of critical illness (ie, post-intensive care syndrome) by promoting patient wakefulness, cognition, and mobility. Humanizing the ICU experience is the key, preserving patients' function and autonomy. Successful implementation requires cultivating an ICU culture focused on avoiding sedatives and initiating prompt mobilization, addressing organizational barriers through tailored strategies. Overall, these patient-centered, mobility-focused models offer a holistic solution to the complex challenge of preventing post-intensive care syndrome and supporting critical illness survivors.

"It Kills Your Soul": A Mixed Methods Study of Ethical Sensitivity of Critical Care Nurses

BACKGROUND

Critically ill patients often experience distressful and impactful symptoms and conditions that include pain, agitation/sedation, delirium, immobility, and sleep disturbances (PADIS). The presence of PADIS can affect recovery and long-term patient outcomes. An integral part of critical care nursing is PADIS prevention, assessment, and management. Ethical sensitivity of everyday nursing practice related to PADIS is an imperative part of implementing evidence-based care for patients.

OBJECTIVE

The first 2 aims of this study were to determine the measured level of ethical awareness as an attribute of ethical sensitivity among the critical care nurse participants and to explore the ethical sensitivity of critical care nurses related to the implementation of PADIS care. The third aim was to examine how the measured level of ethical awareness and ethical sensitivity exploration results converge, diverge, and/or relate to each other to produce a more complete understanding of PADIS ethical sensitivity by critical care nurses.

METHODS

This was a convergent parallel mixed methods study (QUAL + quant). Ethical sensitivity was explored by conducting an ethnography of critical care nurses. The participants were 19 critical care nurses who were observed during patient care, interviewed individually, participated in a focus group (QUAL), and were administered the Ethical Awareness Scale (quant).

FINDINGS

Despite high levels of individual ethical awareness among nurses, themes of ambiguous beneficence, heedless autonomy, and moral distress were found to be related to PADIS care.

CONCLUSIONS

More effort is needed to establish moral community, ethical leadership, and individual ethical guidance for nurses to establish patient-centered decision-making and PADIS care.

Barriers to Implementing the ICU Liberation Bundle in a Single-center Pediatric and Cardiac ICUs

Objectives: The intensive care unit (ICU) Liberation "ABCDEF" Bundle improves outcomes in critically ill adults. We aimed to identify common barriers to Pediatric ICU Liberation Bundle element implementation, to describe differences in barrier perception by ICU staff role, and to describe changes in reported barriers over time. Study Design: A 91-item survey was developed based on existing literature, iteratively revised, and tested by the PICU Liberation Committee at Seattle Children's Hospital, a tertiary free-standing academic children's hospital. Voluntary surveys were administered electronically to all ICU staff twice over 4-week periods in 2017 and 2020. Survey Respondents: 119 (2017) and 163 (2020) pediatric and cardiac ICU staff, including nurses (n = 142, 50%), respiratory therapists (RTs) (n = 46, 16%), attending and fellow physicians, hospitalists, and advanced practice providers (APPs) (n = 62, 22%), physical, occupational, and speech-language pathology therapists (n = 25, 9%), and pharmacists (n = 7, 2%). Measurements and Main Results: Respondents widely agreed that increased workload (78%-100% across roles), communication (53%-84%), and lack of RT-directed ventilator weaning (68%-88%) are barriers to implementation. Other barriers differed by role. In 2020, nurses reported liability (59%) and personal injury (68%) concerns, patient severity of illness (24%), and family discomfort with ICU liberation practices (41%) more frequently than physicians and APPs (16%, 6%, 8%, and 19%, respectively; P < .01 for all). Between 2017 and 2020, some barriers changed: RTs endorsed discomfort with early mobilization less frequently (50% vs 11%, P = .028) and nurses reported concern for patient harm less frequently (51% vs 24%, P = .004). Conclusions: Implementation efforts aimed at addressing known barriers, including educating staff on the safety of early mobility, considering respiratory therapist-directed ventilator weaning, and standardizing interdisciplinary discussion of Pediatric ICU Liberation Bundle elements, will be needed to overcome barriers and improve ICU Liberation Bundle implementation.

Mediator Effects of Cognitive Load on Association between Self-Efficacy and Task Load in Intensive Care Unit Nurses

Aims

To explore the mediating effect of cognitive load on the relationship between self-efficacy and task load among intensive care unit (ICU) nurses.

Background

Studies related to ICU nurses' self-efficacy, cognitive load, and task load are noteworthy but limited.

Methods

A total of 253 ICU nurses from three tertiary hospitals in Beijing were recruited and investigated by the Chinese version of the National Aeronautics and Space Administration-Task Load Index (NASA-TLX), General Self-Efficacy Scale (GSES), and an instrument for Measuring Different Types of Cognitive Load (MDT-CL) scales. SPSS 25.0 was used for Pearson correlation analysis and multiple linear regression analysis and mediation effect analysis using Model 4 in PROCESS (5,000 resamples).

Results

Mediation analysis indicated that a partial mediating effect of extraneous cognitive load between self-efficacy and task load among ICU nurses was -0.707 (95% CI: -0.940, -0.504), accounting for 51.64% of the total effect.

Conclusion

This study suggests that enhancing ICU nurses' self-efficacy can be a potential strategy to decrease extraneous cognitive load and task load. Implications for Nursing Management. Nursing administrators should actively implement intervention strategies based on influencing the task load pathway of ICU nurses to ensure they can provide safe and high-quality nursing services.

Lessons Learned From a Systematic, Hospital-Wide Implementation of the ABCDEF Bundle: A Survey Evaluation

Objective

We recently reported the first part of a study testing the impact of data literacy training on "assessing pain, spontaneous awakening and breathing trials, choice of analgesia and sedation, delirium monitoring/management, early exercise/mobility, and family and patient empowerment" [ABCDEF [A-F]) compliance. The purpose of the current study, part 2, was to evaluate the effectiveness of the implementation approach by surveying clinical staff to examine staff knowledge, skill, motivation, and organizational resources.

DESIGN

The Clark and Estes Gap Analysis framework was used to study knowledge, motivation, and organization (KMO) influences. Assumed influences identified in the literature were used to design the A-F bundle implementation strategies. The influences were validated against a survey distributed to the ICU interprofessional team.

SETTING

Single-center study was conducted in eight adult ICUs in a quaternary academic medical center.

SUBJECTS

Interprofessional ICU clinical team.

INTERVENTIONS

A quantitative survey was sent to 386 participants to evaluate the implementation design postimplementation. An exploratory factor analysis was performed to understand the relationship between the KMO influences and the questions posed to validate the influence. Descriptive statistics were used to identify strengths needed to sustain performance and weaknesses that required improvement to increase A-F bundle adherence.

MEASUREMENT AND RESULTS

The survey received an 83% response rate. The exploratory factor analysis confirmed that 38 of 42 questions had a strong relationship to the KMO influences, validating the survey's utility in evaluating the effectiveness of implementation design. A total of 12 KMO influences were identified, 8 were categorized as a strength and 4 as a weakness of the implementation.

CONCLUSIONS

Our study used an evidence-based gap analysis framework to demonstrate key implementation approaches needed to increase A-F bundle compliance. The following drivers were recommended as essential methods required for successful protocol implementation: data literacy training and performance monitoring, organizational support, value proposition, multidisciplinary collaboration, and interprofessional teamwork activities. We believe the learning generated in this two-part study is applicable to implementation design beyond the A-F bundle.

Effect of the clinical decision assessment system on clinical outcomes of delirium in hospitalized older adults: study protocol for a pair-matched, parallel, cluster randomized controlled superiority trial

BACKGROUND

Prompt recognition of delirium is the first key step in its proper management. A previous study has demonstrated that nurses' delirium screening using the usual paper version assessment tool has no effect on clinical outcomes. Clinical decision assessment systems have been demonstrated to improve patients' adherence and clinical outcomes. Therefore, We developed a clinical decision assessment system (3D-DST) based on the usual paper version (3-min diagnostic interview for CAM-defined delirium), which was developed for assessing delirium in older adults with high usability and accuracy. However, no high quality evidence exists on the effectiveness of a 3D-DST in improving outcomes of older adults compared to the usual paper version.

METHODS

A pair-matched, open-label, parallel, cluster randomized controlled superiority trial following the SPIRIT checklist. Older patients aged 65 years or older admitted to four medical wards of a geriatric hospital will be invited to participate in the study. Prior to the study, delirium prevention and treatment interventions will be delivered to nurses in both the intervention and control groups. The nurses in the intervention group will perform routine delirium assessments on the included older patients with 3D-DST, while the nurses in the control group will perform daily delirium assessments with the usual paper version. Enrolled patients will be assessed twice daily for delirium by a nurse researcher using 3D-DST. The primary outcome is delirium duration. The secondary outcomes are delirium severity, incidence of delirium, length of stay, in-hospital mortality, adherence to delirium assessment, prevention, and treatment of medical staff.

DISCUSSION

This study will incorporate the 3D-DST into clinical practice for delirium assessment. If our study will demonstrate that 3D-DST will improve adherence with delirium assessment and clinical outcomes in older patients, it will provide important evidence for the management of delirium in the future.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, Identifier: ChiCTR1900028402. https://www.chictr.org.cn/showproj.aspx?proj=47127 .

PROTOCOL VERSION

1, 29/7/22.

An Exploration of Critical Care Professionals' Strategies to Enhance Daily Implementation of the Assess, Prevent, and Manage Pain; Both Spontaneous Awakening and Breathing Trials; Choice of Analgesia and Sedation; Delirium Assess, Prevent, and Manage; Early Mobility and Exercise; and Family Engagement and Empowerment: A Group Concept Mapping Study

The goals of this exploratory study were to engage professionals from the Society for Critical Care Medicine ICU Liberation Collaborative ICUs to: 1) conceptualize strategies to enhance daily implementation of the Assess, prevent, and manage pain; Both spontaneous awakening and breathing trials; Choice of analgesia and sedation; Delirium assess, prevent, and manage; Early mobility and exercise; and Family engagement and empowerment (ABCDEF) bundle from different perspectives and 2) identify strategies to prioritize for implementation.

DESIGN

Mixed-methods group concept mapping over 8 months using an online method. Participants provided strategies in response to a prompt about what was needed for successful daily ABCDEF bundle implementation. Responses were summarized into a set of unique statements and then rated on a 5-point scale on degree of necessity (essential) and degree to which currently used.

SETTING

Sixty-eight academic, community, and federal ICUs.

PARTICIPANTS

A total of 121 ICU professionals consisting of frontline and leadership professionals.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A final set of 76 strategies (reduced from 188 responses) were suggested: education (16 strategies), collaboration (15 strategies), processes and protocols (13 strategies), feedback (10 strategies), sedation/pain practices (nine strategies), education (eight strategies), and family (five strategies). Nine strategies were rated as very essential but infrequently used: adequate staffing, adequate mobility equipment, attention to (patient's) sleep, open discussion and collaborative problem solving, nonsedation methods to address ventilator dyssynchrony, specific expectations for night and day shifts, education of whole team on interdependent nature of the bundle, and effective sleep protocol.

CONCLUSIONS

In this concept mapping study, ICU professionals provided strategies that spanned a number of conceptual implementation clusters. Results can be used by ICU leaders for implementation planning to address context-specific interdisciplinary approaches to improve ABCDEF bundle implementation.

Factors Associated With Spontaneous Awakening Trial and Spontaneous Breathing Trial Performance in Adults With Critical Illness: Analysis of a Multicenter, Nationwide, Cohort Study

BACKGROUND

Broad-scale adoption of spontaneous awakening trials (SATs) and spontaneous breathing trials (SBTs) into everyday practice has been slow, and uncertainty exists regarding what factors facilitate or impede their routine delivery.

RESEARCH QUESTION

What patient, practice, and pharmacologic factors are associated with SAT and SBT performance and to what extent do they predict overall SAT/SBT performance?

STUDY DESIGN AND METHODS

This secondary analysis used data collected from a national quality improvement collaborative composed of 68 diverse ICUs. Adults with critical illness adults who received mechanical ventilation and/or continuously infused sedative medications were included. We performed mixed-effects logistic regression modeling, created receiver operating characteristic curves, and calculated the area under the curve (AUC).

RESULTS

Included in the SAT and SBT analysis were 4,847 and 4,938 patients, respectively. In multivariable models controlling for admitting patient characteristics, factors independently associated with higher odds of a next-day SAT and SBT included physical restraint use (adjusted odds ratio [AOR], 1.63; 95% CI, 1.42-1.87; AOR, 1.83; 95% CI, 1.60-2.09), documented target sedation level (AOR, 1.68; 95% CI, 1.41-2.01; AOR, 1.46; 95% CI, 1.24-1.72), more frequent level of arousal assessments (AOR, 1.22; 95% CI, 1.03-1.43; AOR, 1.32; 95% CI, 1.13-1.54), and dexmedetomidine administration (AOR, 1.23; 95% CI, 1.05-1.45; AOR, 1.52; 95% CI, 1.27-1.80). Factors independently associated with lower odds of a next-day SAT and SBT included deep sedation/coma (AOR, 0.69; 95% CI, 0.60-0.80; AOR, 0.33; 95% CI, 0.28-0.37) and benzodiazepine (AOR, 0.83; 95% CI, 0.72-0.95; AOR, 0.67; 95% CI, 0.59-0.77) or ketamine (AOR, 0.34; 95% CI, 0.16-0.71; AOR, 0.40; 95% CI, 0.18-0.88) administration. Models incorporating admitting, daily, and unit variations displayed moderate discriminant accuracy in predicting next-day SAT (AUC, 0.73) and SBT (AUC, 0.72) performance.

INTERPRETATION

There are a number of modifiable factors associated with SAT/SBT performance that are amenable to the development and testing of implementation interventions.

ABCDE and ABCDEF care bundles: A systematic review of the implementation process in intensive care units

BACKGROUND

The ABCDE (Awakening and Breathing Coordination of daily sedation and ventilator removal trials, Delirium monitoring and management, and Early mobility and exercise) and ABCDEF (Assessment, prevent and manage pain, Both spontaneous awakening and spontaneous breathing trials, Choice of analgesia and sedation, assess, prevent and manage Delirium, Early mobility and exercise, Family engagement) care bundles consist of small sets of evidence-based interventions and are part of the science behind Intensive Care Unit (ICU) liberation. This review sought to analyse the process of implementation of ABCDE and ABCDEF care bundles in ICUs, identifying barriers, facilitators and changes in perception and attitudes of healthcare professionals; and to estimate care bundle effectiveness and safety.

METHODS

We selected qualitative and quantitative studies addressing the implementation of ABCDE and ABCDEF bundles in the ICU, identified on MEDLINE, Embase, CINAHL, The Cochrane Library, Web of Science, Epistemonikos, PsycINFO, Virtual Health Library and Open Grey, without restriction on language or date of publication, up to June 2018. The outcomes measured were ICU and hospital length of stay; mechanical ventilation time; incidence and prevalence of delirium or coma; level of agitation and sedation; early mobilization; mortality in ICU and hospital; change in perception, attitude or behaviour of the stakeholders; and change in knowledge of health professionals. Two reviewers independently selected the studies, performed data extraction, and assessed risk of bias and methodological quality. A meta-analysis of random effects was performed.

RESULTS

Twenty studies were included, 13 of which had a predominantly qualitative and 7 a quantitative design (31,604 participants). The implementation strategies were categorized according to the taxonomy developed by the Cochrane Effective Practice and Organization of Care Group and eighty strategies were identified. The meta-analysis results showed that implementation of the bundles may reduce length of ICU stay, mechanical ventilation time, delirium, ICU and hospital mortality, and promoted early mobilization in critically-ill patients.

CONCLUSIONS

: This study can contribute to the planning and execution of the implementation process of ABCDE and ABCDEF care bundles in ICUs. However, the effectiveness and safety of these bundles need to be corroborated by further studies with greater methodological rigor.

PROTOCOL REGISTRATION

PROSPERO CRD42019121307.

Effects of social influence and implementation climate and leadership on nurse-led early mobility behaviours in critical care

Introduction

Early mobility (EM), initiating and advancing physical activity in the earliest days of critical illness, has been described as the most difficult component of the ABCDEF bundle to implement and coordinate. Successful implementation of EM in clinical practice requires multiple targeted implementation strategies.

Objective

Describe the associations of nurses’ EM attitudes, subjective norms, perceived behavioural control, intention, and implementation climate and leadership with self-reported and documented EM behaviour in the intensive care unit (ICU).

Design

This was a two-site, descriptive, cross-sectional study to explore nurses’ perception of the factors influencing EM adherence.

Setting

Three ICUs (medical, surgical and cardiovascular) in an academic medical centre and two ICUs (medical/surgical and cardiovascular) in a regional medical centre in middle Tennessee.

Patients

Critically ill adults.

Interventions

None.

Main outcome measures

A 34-item investigator-developed survey, Implementation Leadership Scale, and Implementation Climate Scale were administered to ICU nurses. Survey development was informed by a Theory of Planned Behavior based elicitation study and implementation science frameworks.

Results

The academic medical centre had markedly lower EM documentation. We found no difference in nurses’ EM attitudinal beliefs, social influence, facilitators, and barriers at both sites. Nurses perceived moderate social influence to perform EM similarly across sites and considerable control over their ability to perform EM. We did note site differences for implementation climate and leadership and objective EM adherence with the regional community medical centre demonstrating statistically significant relationships of implementation climate and leadership with self-report and documented EM behaviours.

Conclusions

We identified contextual differences in implementation climate and leadership influence when comparing nurse EM behaviours. Streamlined documentation, leadership advocacy for interprofessional coordination and manpower support, and multicomponent context-based implementation strategies could contribute to better EM adherence.

Development of a scale measuring the difficulties faced by nurses who care for patients with delirium in intensive care units

BACKGROUND

Delirium in patients in the intensive care unit is associated with adverse outcomes. Nurses experience many difficulties in caring for those with delirium, which can lead to nurse burnout, prevent effective care for patients, and negatively impact the patient. The identification of factors creating challenges for nurses is, therefore, important to enable intervention.

OBJECTIVES

The aim of this study was to develop a new scale to assess the difficulties faced by nurses caring for patients with delirium in the intensive care unit and to examine its reliability and validity.

METHODS

We based our draft scale items on literature reviews and interviews. Four experts evaluated the collected items. After a pilot study, 211 nurses working in intensive care units in Japan completed the questionnaire. Subsequent statistical analysis of results included factor validity, construct validity, known-group validity, internal consistency, and test-retest reliability.

RESULTS

Exploratory factor analysis extracted a scale of 33 items with eight factors and an additional scale of four items with one factor. The analysis of construct validity suggested a possible association with the Strain of Care for Delirium Index. In the known-group validity, a comparison with two groups based on experience in the intensive care unit found significant differences among the five factors. Internal consistency (Cronbach's α = 0.68-.87) and test-retest reliability (intraclass correlation coefficients = .46-.62) were confirmed.

CONCLUSION

We developed a difficulty scale for nurses caring for patients with delirium in the intensive care unit and confirmed its reliability and validity. The difficulty factors were developed with the intention to identify educational interventions for nurses and the introduction of new organisational resources, such as manpower and providing emotional support and feedback to nurses.

Modified ABCDEF-Bundles for Critically Ill Pediatric Patients - What Could They Look Like?

Background and Significance

Advances in pediatric intensive care have led to markedly improved survival rates in critically ill children. Approximately 70% of those children survive with varying forms of complex chronic diseases or impairment/disabilities. Length of stay, length of mechanical ventilation and number of interventions per patient are increasing with rising complexity of underlying diseases, leading to increasing pain, agitation, withdrawal symptoms, delirium, immobility, and sleep disruption. The ICU-Liberation Collaborative of the Society of Critical Care Medicine has developed a number of preventative measures for prevention, early detection, or treatment of physical and psychiatric/psychological sequelae of oftentimes traumatic intensive care medicine. These so called ABCDEF-Bundles consist of elements for (A) assessment, prevention and management of pain, (B) spontaneous awakening and breathing trials (SAT/SBT), (C) choice of analgesia and sedation, (D) assessment, prevention and management of delirium, (E) early mobility and exercise and (F) family engagement and empowerment. For adult patients in critical care medicine, research shows significant effects of bundle-implementation on survival, mechanical ventilation, coma, delirium and post-ICU discharge disposition. Research regarding PICS in children and possible preventative or therapeutic intervention is insufficient as yet. This narrative review provides available information for modification and further research on the ABCDEF-Bundles for use in critically ill children.

Material and Methods

A narrative review of existing literature was used.

Results

One obvious distinction to adult patients is the wide range of different developmental stages of children and the even closer relationship between patient and family. Evidence for pediatric ABCDEF-Bundles is insufficient and input can only be collected from literature regarding different subsections and topics.

Conclusion

In addition to efforts to improve analgesia, sedation and weaning protocols with the aim of prevention, early detection and effective treatment of withdrawal symptoms or delirium, efforts are focused on adjusting ABCDEF bundle for the entire pediatric age group and on strengthening families' decision-making power, understanding parents as a resource for their child and involving them early in the care of their children.

The impact of ABCDE bundle implementation on patient outcomes: A nationwide cohort study

BACKGROUND

The ABCDE bundle is a set of evidence-based practices to systematically reduce the risks of sedation, delirium, and immobility in intensive care patients. Implementing the bundle improves clinical outcome.

AIMS AND OBJECTIVES

To investigate the association between patient outcomes and compliance with bundle components ABC (analgosedation algorithms), D (delirium protocol), and E (early mobilization protocol).

DESIGN

A Spanish multicentre cohort study of adult patients receiving invasive mechanical ventilation (IMV) for ≥48 h until extubation.

METHODS

The primary outcome was pain level, cooperation to permit Medical Research Council Scale administration, patient days of delirium, and mobility. The secondary outcome was cumulative drug dosing by IMV days. Tertiary outcomes (ICU days, IMV days, bed rest days, ICU mortality, ICUAW) and independent variables (analgosedation, delirium, early mobilization protocols) were also studied.

RESULTS

Data were collected from 605 patients in 80 ICUs and 5214 patient days with IMV. Two-thirds of the ICUs studied applied no protocols. Pain was not assessed on 83.6% of patient days. Patient cooperation made scale administration feasible on 20.7% of days. Delirium and immobility were found on 4.2% and 69.9% of days, respectively. Patients had shorter stays in ICUs with bundle protocols and fewer days of IMV in ICUs with delirium and mobilization bundle components (P = 0.006 and P = 0.03, respectively). Analgosedation protocols were associated with more opioid dosing (P = 0.02), and delirium and early mobilization protocols with more propofol (P = 0.001), dexmedetomidine (P = 0.001), and lower benzodiazepine dosing (P = 0.008).

CONCLUSIONS

The implementation rate of ABCDE bundle components was very low in our Spanish setting, but when implemented, patients had a shorter ICU stay, more analgesia dosing, and lighter sedation.

RELEVANCE TO CLINICAL PRACTICE

Applying some but not all the bundle components, there is increased analgesia and light sedation drug use, decreased benzodiazepines, and increased patient cooperation and mobility, resulting in a shorter ICU stay and fewer days of IMV.

Effect on Quality of Care of a Delirium Prevention Campaign for Surgical Intensive Care Nurses

BACKGROUND

Delirium is an important issue related to mortality in patients treated in intensive care units.

LOCAL PROBLEM

Although there are guidelines for preventing delirium, its importance may be overlooked compared with the treatment of physical illness.

METHODS

A 2-step delirium prevention campaign (DPC) was implemented and its effects compared (before and after the DPC).

INTERVENTIONS

The DPC comprised the Confusion Assessment Method for the Intensive Care Unit and a checklist for delirium prevention.

RESULTS

Hospital mortality declined after the DPC, but there were no significant changes in the incidence and duration of delirium.

CONCLUSIONS

Nurses led the delirium preventive care intervention. Delirium prevention care may be more effective with policy approaches to progress the DPC.

Assess, Prevent, and Manage Pain; Both Spontaneous Awakening and Breathing Trials; Choice of Analgesia/Sedation; Delirium: Assess, Prevent, and Manage; Early Mobility; Family Engagement and Empowerment Bundle Implementation: Quantifying the Association of Access to Bundle-Enhancing Supplies and Equipment

Describe the physical environment factors (i.e., availability, accessibility) of bundle-enhancing items and the association of physical environment with bundle adherence.

DESIGN

This multicenter, exploratory, cross-sectional study used data from two ICU-based randomized controlled trials that measured daily bundle adherence. Unit- and patient-level data collection occurred between 2011 and 2016. We developed hierarchical logistic regression models using Frequentist and Bayesian frameworks.

SETTING

The study included 10 medical and surgical ICUs in six academic medical centers in the United States.

PATIENTS

Adults with qualifying respiratory failure and/or septic shock (e.g., mechanical ventilation, vasopressor use) were included in the randomized controlled trials.

INTERVENTIONS

The Awakening and Breathing trial Coordination, Delirium assessment/management, Early mobility bundle was recommended standard of care for randomized controlled trial patients and adherence tracked daily.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was adherence to the full bundle and the early mobility bundle component as identified from daily adherence documentation (n = 751 patient observations). Models included unit-level measures such as minimum and maximum distances to bundle-enhancing items and patient-level age, body mass index, and daily mechanical ventilation status. Some models suggested the following variables were influential: unit size (larger associated with decreased adherence), a standard walker (presence associated with increased adherence), and age (older associated with decreased adherence). In all cases, mechanical ventilation was associated with decreased bundle adherence.

CONCLUSIONS

Both unit- and patient-level factors were associated with full bundle and early mobility adherence. There is potential benefit of physical proximity to essential items for Awakening and Breathing trial Coordination, Delirium assessment/management, Early mobility bundle and early mobility adherence. Future studies with larger sample sizes should explore how equipment location and availability influence practice.

Effectiveness of Bundle Interventions on ICU Delirium: A Meta-Analysis

OBJECTIVE

To evaluate the impact of bundle interventions on ICU delirium prevalence, duration, and other patients' adverse outcomes.

DATA SOURCES

The Cochrane Library, PubMed, CINAHL, EMBASE, PsychINFO, and MEDLINE from January 2000 to July 2020. The protocol of the study was registered in International prospective register of systematic reviews (CRD42020163147).

STUDY SELECTION

Randomized clinical trials or cohort studies that examined the following outcomes were included in the current study: ICU delirium prevalence and duration, proportion of patient-days with coma, ventilator-free days, mechanical ventilation days, ICU or hospital length of stay, and ICU or inhospital or 28-day mortality.

DATA EXTRACTION

Using a standardized data-collection form, two authors screened the studies and extracted the data independently, and assessed the studies' quality using the Modified Jadad Score Scale for randomized clinical trials and the Newcastle-Ottawa Scale for cohort studies.

DATA SYNTHESIS

Eleven studies with a total of 26,384 adult participants were included in the meta-analysis. Five studies (three randomized clinical trials and two cohort studies) involving 18,638 patients demonstrated that ICU delirium prevalence was not reduced (risk ratio = 0.92; 95% CI, 0.68-1.24). Meta-analysis showed that the use of bundle interventions was not associated with shortening the duration of ICU delirium (mean difference = -1.42 d; 95% CI, -3.06 to 0.22; two randomized clinical trials and one cohort study), increasing ventilator-free days (mean difference = 1.56 d; 95% CI, -1.56 to 4.68; three randomized clinical trials), decreasing mechanical ventilation days (mean difference = -0.83 d; 95% CI, -1.80 to 0.14; four randomized clinical trials and two cohort studies), ICU length of stay (mean difference = -1.08 d; 95% CI, -2.16 to 0.00; seven randomized clinical trials and two cohort studies), and inhospital mortality (risk ratio = 0.86; 95% CI, 0.70-1.06; five randomized clinical trials and four cohort studies). However, bundle interventions are effective in reducing the proportion of patient-days experiencing coma (risk ratio = 0.47; 95% CI, 0.39-0.57; two cohort studies), hospital length of stay (mean difference = -1.47 d; 95% CI, -2.80 to -0.15; four randomized clinical trials and one cohort study), and 28-day mortality by 18% (risk ratio = 0.82; 95% CI, 0.69-0.99; three randomized clinical trials).

CONCLUSIONS

This meta-analysis fails to support that bundle interventions are effective in reducing ICU delirium prevalence and duration, but supports that bundle interventions are effective in reducing the proportion of patient-days with coma, hospital length of stay, and 28-day mortality. Larger randomized clinical trials are needed to evaluate the impact of bundle interventions on ICU delirium and other clinical outcomes.

The ABCDE bundle implementation in an intensive care unit: Facilitators and barriers perceived by nurses and doctors

AIM

To describe the facilitators and barriers perceived by healthcare teams after the implementation of the Awakening, Breathing, Coordination, Delirium monitoring/management and Early mobility bundle in an intensive care unit in Italy. This multicomponent intervention strategy has been associated with lower probabilities of delirium, improved functional outcomes and shorter duration of mechanical ventilation.

METHODS

A survey study conducted between June 2015 and May 2016 explored variables related to intensive care unit team members: perceptions of delirium; knowledge of the Awakening, Breathing, Coordination, Delirium monitoring/management and Early mobility bundle; teamwork perception and resource availability.

RESULTS

Most of the participants affirmed having reasonable knowledge of delirium, outcomes of delirious episodes, Awakening, Breathing, Coordination, Delirium monitoring/management and Early mobility bundle components and their effectiveness. Low coordination between healthcare professionals was identified as a barrier. Overall, the time elapsing from the beginning of implementation of the bundle determined an increase in levels of awareness and confidence in the application of the bundle protocol and the Confusion Assessment Method Intensive Care Unit scale.

CONCLUSION

Issues with the Awakening, Breathing, Coordination, Delirium monitoring/management and Early mobility bundle relating to coordination, management and interdisciplinary ward rounds are critical and should be remedied and monitored. This study could provide the basis for improving bundle implementation strategies and surveying levels of progression in other intensive care units.

Variables associated with mobility levels in critically ill patients: A cohort study

BACKGROUND

Early mobilization in the intensive care unit (ICU) helps improve patients' functional status at discharge. However, many barriers hinder this practice.

AIM AND OBJECTIVES

To identify mobility levels acquired by critically ill patients and their variables.

DESIGN

A multi-centre cohort study was conducted in adult patients receiving invasive mechanical ventilation for at least 48 hours.

METHODS

The primary outcome was level of mobility according to the ICU mobility scale. The secondary outcome was human resource availability and existence of ABCDEF bundle guidelines. A logistic regression was performed, based on days 3 to 5 of the ICU stay and significant association with active mobility.

RESULTS

Six hundred and forty-two patients were included from 80 ICUs. Active moving in and out of bed was found on 9.9% of patient-days from day 8 of the ICU stay. Bed exercises, or passive transfers, and immobility were observed on 45.6% and 42.2% of patient-days, respectively. Patients achieving active mobility (189/642, 29.4%) were in ICUs with more physiotherapist hours. Active mobility was more likely with a 1:4 nurse-patient ratio (odds ratio [OR] 3.7 95% confidence interval [CI] [1.2-11.2]), high MRC sum-score (OR 1.05 95% CI [1.04-1.06]) and presence of delirium (OR 1.01 95% CI [1.00-1.02]). By contrast, active mobility was hindered by higher BMI (OR 0.92 95% CI [0.88-0.97]), a 1:3 nurse-patient ratio (OR 0.54 95% CI [0.32-0.93]), or a shift-dependent nurse-patient ratio (OR 0.27 95% CI [0.12-0.62]).

CONCLUSIONS

Immobility and passive mobilization were prevalent. A high MRC sum-score and presence of delirium are protective factors of mobilization. A 1:4 nurse-patient ratio shows a stronger association with active mobility than a 1:3 ratio.

RELEVANCE TO CLINICAL PRACTICE

Severity-criteria-based nurse-patient ratios hinder mobilization. Active mobilization may be enhanced by using nursing-intervention-based ratios, increasing physiotherapist hours, and achieving wider application of the ABCDEF bundle, resulting in more awake, cooperative patients.

Implementation of the "awakening and breathing trials, choice of drugs, delirium management, and early exercise/mobility" bundle in the pediatric intensive care unit of tertiary hospitals in southwestern China: a cross-sectional survey

Objective

To investigate management and implementation of the “awakening and breathing trials, choice of drugs, delirium management, and early exercise/mobility” (ABCDE) bundle in the pediatric intensive care unit (PICU) in southwestern China

Methods

A self-designed questionnaire for determining implementation of the ABCDE bundle was distributed to healthcare professionals in the PICU. Multiple linear regression was used to analyze results.

Results

A total of 270 questionnaires were collected. There was no significant difference in the awareness of the ABCDE bundle rate among Sichuan, Guizhou, and Yunnan workers. Only dynamic adjustment of drug dose accounted for more than half (55.5%) of “frequent implementation” and “general implementation”, followed by implementation of sedation assessment, pain assessment, and spontaneous breathing trials (46.4%, 39.3%, and 35.6%, respectively). A total of 80.4% of healthcare professionals never performed screening of delirium. Multivariate analysis showed that the healthcare professionals’ scores of ABCDE bundle behavior significantly differed regarding awareness of the ABCDE bundle, years of work at the hospital, the region of hospitals, and occupational category.

Conclusion

Implementation of the ABCDE bundle in the PICU in southwestern China is not sufficient. Existing problems need to be identified and a standardized sedation and analgesia management model needs to be established.

Patient-Level Barriers and Facilitators to Early Mobilization and the Relationship With Physical Disability Post-Intensive Care: Part 2 of an Integrative Review Through the Lens of the World Health Organization International Classification of Functioning, Disability, and Health

BACKGROUND

Early mobilization (EM) is associated with reduced physical disability post-intensive care (PD PIC). Yet, contextual factors facilitate or impede delivery of EM in the intensive care unit (ICU). Only 45% of ICUs in the United States routinely practice EM despite its recognized benefits.

OBJECTIVES

To analyze the evidence on the relationship between critical care EM, PD PIC, and personal (patient-level) factors, using the theoretical lens of the World Health Organization's International Classification of Functioning, Disability, and Health (ICF).

METHOD

The Whittemore and Knafl methodology for integrative reviews and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) reporting guidelines were followed. Qualitative, quantitative, and mixed-methods studies (n = 38) that evaluated EM and 1 or more domains of the World Health Organization ICF were included. Quality was appraised using the Mixed-Methods Appraisal Tool. Study characteristics were evaluated for common themes and relationships. The ICF domains and subdomains pertaining to each study were synthesized.

RESULTS

Early mobilization delivery was influenced by personal factors. Deeper sedation level, the presence of delirium, higher patient acuity, the presence of medical devices, and patient weight were identified barriers to EM delivery. Patient engagement in EM was associated with improved delivery. Patients who enjoyed rehabilitation were more likely to demonstrate improvement in functional impairment than those who did not enjoy rehabilitation.

DISCUSSION

Early mobilization is associated with reduced PD PIC, yet numerous contextual factors affect the delivery of EM in the ICU. Further study of patient-level factors and EM must explore the relationship between patient engagement, baseline demographics, and functional status at ICU admission, patient-level considerations for decisions to mobilize, and EM in the ICU. This research is critical to improving the delivery of EM in the ICU and reducing PD PIC.

Environmental Factors Affecting Early Mobilization and Physical Disability Post-Intensive Care: An Integrative Review Through the Lens of the World Health Organization International Classification of Functioning, Disability, and Health

BACKGROUND

Early mobilization (EM) is one of few potential protective factors associated with reduced physical disability post-intensive care (PD PIC). However, only 45% of intensive care units (ICUs) in the United States routinely practice EM despite its recognized benefits.

OBJECTIVES

To analyze the evidence on the relationship between critical care EM, PD PIC, and environmental factors, using the theoretical lens of the World Health Organization's (WHO's) International Classification of Functioning, Disability, and Health (ICF).

METHOD

The Whittemore and Knafl methodology for integrative reviews and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) reporting guidelines were followed. Qualitative, quantitative, and mixed-methods studies (n = 38) that evaluated EM and 1 or more domains of the WHO ICF were included. Quality was appraised using the Mixed-Methods Appraisal Tool. Study characteristics were evaluated for common themes and relationships. The ICF domains and subdomains pertaining to each study were synthesized.

RESULTS

Early mobilization was related to improved functioning on the disability continuum of the WHO ICF. Early mobilization was influenced by several WHO ICF environmental factors. Dedicated physical and occupational therapy teams in the ICU, interdisciplinary rounds, and positive family and staff perception of EM facilitated intervention delivery. However, poor staffing levels, negative unit culture, perceived workload burden, and lack of equipment, education, and financial support impeded delivery of EM.

DISCUSSION

Early mobilization is a promising intervention that may reduce PD PIC. However, environmental factors negatively influence delivery of EM in the ICU. Several gaps in EM research limit its acceptability in ICU practice. Existing EM research is challenged by poor methodological quality. Further study is necessary to better understand the role of EM on PD PIC and improve patient outcomes following critical illness.

Prevention and Management of Delirium in the Intensive Care Unit

Delirium is a debilitating form of brain dysfunction frequently encountered in the intensive care unit (ICU). It is associated with increased morbidity and mortality, longer lengths of stay, higher hospital costs, and cognitive impairment that persists long after hospital discharge. Predisposing factors include smoking, hypertension, cardiac disease, sepsis, and premorbid dementia. Precipitating factors include respiratory failure and shock, metabolic disturbances, prolonged mechanical ventilation, pain, immobility, and sedatives and adverse environmental conditions impairing vision, hearing, and sleep. Historically, antipsychotic medications were the mainstay of delirium treatment in the critically ill. Based on more recent literature, the current Society of Critical Care Medicine (SCCM) guidelines suggest against routine use of antipsychotics for delirium in critically ill adults. Other pharmacologic interventions (e.g., dexmedetomidine) are under investigation and their impact is not yet clear. Nonpharmacologic interventions thus remain the cornerstone of delirium management. This approach is summarized in the ABCDEF bundle (Assess, prevent, and manage pain; Both SAT and SBT; Choice of analgesia and sedation; Delirium: assess, prevent, and manage; Early mobility and exercise; Family engagement and empowerment). The implementation of this bundle reduces the odds of developing delirium and the chances of needing mechanical ventilation, yet there are challenges to its implementation. There is an urgent need for ongoing studies to more effectively mitigate risk factors and to better understand the pathobiology underlying ICU delirium so as to identify additional potential treatments. Further refinements of therapeutic options, from drugs to rehabilitation, are current areas ripe for study to improve the short- and long-term outcomes of critically ill patients with delirium.

Challenges of Delirium Management in Patients with Traumatic Brain Injury: From Pathophysiology to Clinical Practice

Traumatic brain injury (TBI) can initiate a very complex disease of the central nervous system (CNS), starting with the primary pathology of the inciting trauma and subsequent inflammatory and CNS tissue response. Delirium has long been regarded as an almost inevitable consequence of moderate to severe TBI, but more recently has been recognized as an organ dysfunction syndrome with potentially mitigating interventions. The diagnosis of delirium is independently associated with prolonged hospitalization, increased mortality and worse cognitive outcome across critically ill populations. Investigation of the unique problems and management challenges of TBI patients is needed to reduce the burden of delirium in this population. In this narrative review, possible etiologic mechanisms behind post-traumatic delirium are discussed, including primary injury to structures mediating arousal and attention and secondary injury due to progressive inflammatory destruction of the brain parenchyma. Other potential etiologic contributors include dysregulation of neurotransmission due to intravenous sedatives, seizures, organ failure, sleep cycle disruption or other delirium risk factors. Delirium screening can be accomplished in TBI patients and the presence of delirium portends worse outcomes. There is evidence that multi-component care bundles including an analgesia-prioritized sedation algorithm, regular spontaneous awakening and breathing trials, protocolized delirium assessment, early mobility and family engagement can reduce the burden of ICU delirium. The aim of this review is to summarize the approach to delirium in TBI patients with an emphasis on pathogenesis and management. Emerging CNS-active drug therapies that show promise in preclinical studies are highlighted.

Intensive Care Unit Nursing Priorities in the United States

This integrative review presents the most recent and relevant critical care nursing research publications in the United States. A comprehensive search identified publications on the topics of delirium; early mobility; communication; palliative care; tele-intensive care unit; care bundle implementation; and prevention, detection, and early management of infection. The evidence is summarized for each of these topics, as well as other research, with suggestions and guidance for end users.

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

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.

Factors associated with ABCDE bundle adherence in critically ill adults requiring mechanical ventilation: An observational design

OBJECTIVE

To identify factors associated with the ABCDEF bundle (Assess, prevent, and manage pain, Both, spontaneous awakening and breathing trials, Choice of sedation/analgesia, Delirium assess, prevent and manage, Early mobility/exercise and Family engagement/empowerment) adherence, in critically ill patients during the first 96 hours of mechanical ventilation.

DESIGN

Observational study using electronic health record data.

SETTING

15 intensive care units located in seven community hospitals in a western United States health system.

PATIENTS

977 adult patients who were on mechanical ventilation for greater than 24 hours and admitted to an intensive care unit over six months.

MEASUREMENTS AND MAIN RESULTS

Multiple regression analysis was used to examine factors contributing to bundle adherence while adjusting for severity of illness, days on mechanical ventilation, hospital site and time elapsed. ABCDEF bundle adherence was higher in patients on mechanical ventilation for less than 48 hours (p = 0.01), who received continuous sedation for less than 24 hours (p < 0.001), admitted from skilled nursing facilities (p < 0.05), and over the course of the six-month study period (p < 0.01). Bundle adherence was significantly lower for Hispanic patients (p < 0.01).

CONCLUSIONS

Our study identified potentially modifiable factors that could improve the team's performance of the ABCDEF bundle in patients requiring mechanical ventilation.

Strategies to effect change in the ICU

PURPOSE OF REVIEW

To provide an update on implementation efforts in the care of critically ill patients, with a focus on work published in the last 2 years.

RECENT FINDINGS

Only half of surveyed members of the multidisciplinary care team in the ICU were aware of the Choosing Wisely campaign, and of those that were, approximately one-third reported no implementation of the recommendations. Barriers to implementation of the ABCDE bundle extend to beyond patient-level domains, and include clinician-related, protocol-related, and other domains. Prospective audit and feedback approaches have demonstrated moderate success for improving the quality of antibiotic prescription practices in the ICU.

SUMMARY

Clinical research in intensive care has moved beyond simple discovery and dissemination. Best practices must be applied to effect change in ICU care, requiring the application of principles from implementation science. Future work should move beyond simple before-after evaluations to provide a stronger case for causal inference following implementation efforts.

Variation in the Management of Pain, Agitation, and Delirium in Intensive Care Units in British Columbia

BACKGROUND

Pain, agitation, and delirium are associated with negative outcomes in critically ill patients. Reducing variation in pain, agitation, and delirium management among institutions could improve care.

OBJECTIVES

To define opportunities to improve pain, agitation, and delirium management in intensive care units in British Columbia, Canada.

METHODS

A 13-item survey was developed to determine practices for assessing and managing pain, agitation, and delirium. Target participants were persons designated as the most informed about pain, agitation, and delirium management at each of the 30 intensive care units in British Columbia. Main measures were protocol use, assessment tool(s) used and frequency, and management approaches.

RESULTS

All 30 units responded; half of them had a unit-specific pain algorithm. The Behavioral Pain Scale and the numerical rating scale were the most common tools used to assess pain. Sites reported 15 different approaches to pain management: two-thirds used a sedation assessment tool, but some relied on physician diagnoses to identify sedation. Sites reported 18 different approaches to sedation management: most included an algorithm or order set for sedation management, but the most commonly used approach was individualized management by a clinician (17% for sedation and 30% for agitation). Sites reported 22 different approaches for delirium management: more than two-thirds used a delirium measurement instrument, but some relied on physician diagnoses to identify delirium.

CONCLUSION

Variation in assessment and management of pain, agitation, and delirium in British Columbia intensive care units highlights opportunities to improve care.

An acceptability pilot of the facilitating active management in lung illness with engaged surrogates (FAMILIES) study

Approximately half of the surrogate decision makers of critically ill adults are at risk for negative emotional burden. Decision support and effective surrogate-clinician communication buffers against such experiences. The objective of this study is to evaluate the acceptability of a new surrogate-targeted educational tool that promotes engagement with clinicians and advocacy for 2 evidence-based practices in the provision of mechanical ventilation for acute respiratory failure: spontaneous awakening and breathing trials.A panel of 44 former patients and surrogates of a 20-bed medical intensive care unit in a large academic hospital responded to an online survey. Acceptability was measured on 3 dimensions: attitudes toward the content and delivery of information, objective knowledge translation, and subjective knowledge acquisition.More than 80% of participants found the tool to be easy to read, and over 90% felt that the tool provided actionable recommendations. A significant number of previously unsure participants were able to identify what spontaneous awakening and breathing trials are and when they occur, and 16% to 36% reported significant improvements in their subjective understanding of the target evidence-based practices, after being exposed to the educational tool.This line of work seeks to reduce surrogates' negative emotional burden while also promoting quality critical care. The educational tool provides a promising new way to promote surrogate-clinician communication, by increasing surrogates' knowledge about and encouraging advocacy for evidence-based practices in the provision of mechanical ventilation.

Implementing the ABCDEF Bundle: Top 8 Questions Asked During the ICU Liberation ABCDEF Bundle Improvement Collaborative

The ABCDEF bundle (A, assess, prevent, and manage pain; B, both spontaneous awakening and spontaneous breathing trials; C, choice of analgesic and sedation; D, delirium: assess, prevent, and manage; E, early mobility and exercise; and F, family engagement and empowerment) improves intensive care unit patient-centered outcomes and promotes interprofessional teamwork and collaboration. The Society of Critical Care Medicine recently completed the ICU Liberation ABCDEF Bundle Improvement Collaborative, a 20-month, multicenter, national quality improvement initiative that formalized dissemination and implementation strategies to promote effective adoption of the ABCDEF bundle. The purpose of this article is to describe 8 of the most frequently asked questions during the Collaborative and to provide practical advice from leading experts to other institutions implementing the ABCDEF bundle.

Occupational Therapy in the ICU: A Scoping Review of 221 Documents

OBJECTIVES

Occupational therapists have specialized expertise to enable people to perform meaningful "occupations" that support health, well-being, and participation in life roles. Given the physical, cognitive, and psychologic disability experienced by ICU survivors, occupational therapists could play an important role in their recovery. We conducted a scoping review to determine the state of knowledge of interventions delivered by occupational therapists in adult ICU patients.

DATA SOURCES

Eight electronic databases from inception to 05/2018.

STUDY SELECTION

We included reports of adult patients receiving direct patient care from an occupational therapist in the ICU, all study designs, and quantitative and qualitative traditions.

DATA EXTRACTION

Independently in duplicate, interprofessional team members screened titles, abstracts, and full texts and extracted report and intervention characteristics. From original research articles, we also extracted study design, number of patients, and primary outcomes. We resolved disagreements by consensus.

DATA SYNTHESIS

Of 50,700 citations, 221 reports met inclusion criteria, 74 (79%) published after 2010, and 125 (56%) appeared in critical care journals. The three most commonly reported types of interventions were mobility (81%), physical rehabilitation (61%), and activities of daily living (31%). We identified 46 unique original research studies of occupational therapy interventions; the most common study research design was before-after studies (33%).

CONCLUSIONS

The role of occupational therapists in ICU rehabilitation is not currently well established. Current interventions in the ICU are dominated by physical rehabilitation with a growing role in communication and delirium prevention and care. Given the diverse needs of ICU patients and the scope of occupational therapy, there could be an opportunities for occupational therapists to expand their role and spearhead original research investigating an enriched breadth of ICU interventions.

The ABCDEF Bundle for the Respiratory Therapist

The clinical approach to the critically ill patient has changed dramatically over the last several decades from one of deep sedation to that of mobilizing patients on mechanical ventilation and limiting sedation. The ABCDEF bundle is a multidisciplinary, evidence-based approach to the holistic management of critically ill patients that aims to optimize patient recovery, minimize iatrogenesis, and engage and empower the patient and family during their hospitalization. To achieve this goal, the bundle includes assessments for pain, delirium, and readiness to stop sedation and to start spontaneous breathing trials. It also encourages early mobilization of the patient, avoidance of restraints, and engagement with the family in bedside rounds to improve communication. Performance of this bundle reduces mortality, ventilator days, intensive care readmissions, delirium, coma, restraint use, and discharge to facilities in a dose-dependent manner. The respiratory therapist, as a key member of the critical care team, is essential to the implementation, performance, and success of the ABCDEF bundle. This review aims to describe each component of the ABCDEF bundle, provide evidence for both the impact of individual interventions as well as the entire bundle, and detail the importance of this multidisciplinary approach to the care of the critically ill patient.

[Early mobilisation on the intensive care unit : What we know]

BACKGROUND

Early mobilization is defined as intervention within the first 72 h after intensive care unit (ICU) admission. According to the current state of relevant studies, evidence on early mobilization in critically ill patients is still inconsistent. This leads to insecurity in caretakers and subsequently to incomplete implementation in German ICUs.

OBJECTIVES

What type of intervention is suitable for certain patient groups? Which issues remain unresolved?

RESULTS

To obtain best possible outcomes, early mobilization should be initiated during the first 72 h after ICU admission. Implementation of early mobilization improves clinical outcome and should be integrated in a patient-centered bundle (such as ABCDEF). Mechanical ventilation is not a contraindication to intervention. Evidence in neurocritical care as well as functionally dependent patients is still low. Mode of intervention and dosage of early mobilisation remain unclear.

CONCLUSION

Early mobilization is safe and feasible, resulting in improved outcomes in surgical and medical ICU patients. Further studies are necessary to evaluate the optimal dosage and duration of intervention, especially in neurocritical care patients.

Impact of a nurse engagement intervention on pain, agitation and delirium assessment in a community intensive care unit

Background

In 2013, the Society of Critical Care Medicine published a revised version of the ICU Pain, Agitation, and Delirium (PAD) guidelines. Immobility and sleep were subsequently added in 2018. Despite the well-established advantages of implementing these guidelines, adoption and adherence remain suboptimal. This is especially true in community settings, where PAD assessment is performed less often, and the implementation of PAD guidelines has not yet been studied. The purpose of this prospective interventional study is to evaluate the effect of a multifaceted nurse engagement intervention on PAD assessment in a community intensive care unit (ICU).

Methods

All patients admitted to our community ICU for over 24 hours were included. A 20-week baseline audit was performed, followed by the intervention, and a 20-week postintervention audit. The intervention consisted of a survey, focus groups and education sessions. Primary outcomes included rates of daily PAD assessment using validated tools.

Results

There were improvements in the number of patients with at least one assessment per day of pain (67.5% vs 59.3%, p=0.04), agitation (93.1% vs 78.7%, p<0.001) and delirium (54.2% vs 39.4%, p<0.001), and the number of patients with target Richmond Agitation-Sedation Scale ordered (63.1% vs 46.8%, p=0.002). There was a decrease in the rate of physical restraint use (10.0% vs 30.9%, p<0.001) and no change in self-extubation rate (0.9% vs 2.5%, p=0.2).

Conclusion

The implementation of a multifaceted nurse engagement intervention has the potential to improve rates of PAD assessment in community ICUs. Screening rates in our ICU remain suboptimal despite these improvements. We plan to implement multidisciplinary interventions targeting physicians, nurses and families to close the observed care gap.

Staged Implementation of Awakening and Breathing, Coordination, Delirium Monitoring and Management, and Early Mobilization Bundle Improves Patient Outcomes and Reduces Hospital Costs

OBJECTIVES

To measure the impact of staged implementation of full versus partial ABCDE bundle on mechanical ventilation duration, ICU and hospital lengths of stay, and cost.

DESIGN

Prospective cohort study.

SETTING

Two medical ICUs within Montefiore Healthcare Center (Bronx, NY).

PATIENTS

One thousand eight hundred fifty-five mechanically ventilated patients admitted to ICUs between July 2011 and July 2014.

INTERVENTIONS

At baseline, spontaneous (B)reathing trials (B) were ongoing in both ICUs; in period 1, (A)wakening and (D)elirium (AD) were implemented in both full and partial bundle ICUs; in period 2, (E)arly mobilization and structured bundle (C)oordination (EC) were implemented in the full bundle (B-AD-EC) but not the partial bundle ICU (B-AD).

MEASUREMENTS AND MAIN RESULTS

In the full bundle ICU, 95% patient days were spent in bed before EC (period 1). After EC was implemented (period 2), 65% of patients stood, 54% walked at least once during their ICU stay, and ICU-acquired pressure ulcers and physical restraint use decreased (period 1 vs 2: 39% vs 23% of patients; 30% vs 26% patient days, respectively; p < 0.001 for both). After adjustment for patient-level covariates, implementation of the full (B-AD-EC) versus partial (B-AD) bundle was associated with reduced mechanical ventilation duration (-22.3%; 95% CI, -22.5% to -22.0%; p < 0.001), ICU length of stay (-10.3%; 95% CI, -15.6% to -4.7%; p = 0.028), and hospital length of stay (-7.8%; 95% CI, -8.7% to -6.9%; p = 0.006). Total ICU and hospital cost were also reduced by 24.2% (95% CI, -41.4% to -2.0%; p = 0.03) and 30.2% (95% CI, -46.1% to -9.5%; p = 0.007), respectively.

CONCLUSIONS

In a clinical practice setting, the addition of (E)arly mobilization and structured (C)oordination of ABCDE bundle components to a spontaneous (B)reathing, (A)wakening, and (D) elirium management background led to substantial reductions in the duration of mechanical ventilation, length of stay, and cost.

The Life Course Health Development Model: A theoretical research framework for paediatric delirium

AIMS AND OBJECTIVES

To create a framework for future research through application and critique of the Life Course Health Development Model to the phenomenon of paediatric delirium.

BACKGROUND

Delirium in the paediatric intensive care unit is associated with increased duration of mechanical ventilation, length of stay and mortality. Nurses are uniquely positioned at the bedside to identify, prevent and treat delirium. An understanding of the potential long-term consequences of paediatric delirium is necessary to provide impetus for nursing research and practice change. The Life Course Health Development Model is a valuable tool when considering the multiple mechanisms and processes through which the experience of delirium could affect a child's life trajectory.

DESIGN

Critical review of the literature through application and critique of the Life Course Health Development Model in the context of paediatric delirium. Gaps in the current understanding of paediatric delirium, as well as future directions for research and practice, are discussed.

METHODS

The seven core principles of the model are considered in the context of paediatric delirium. Each of the principles has the potential to further understanding of paediatric delirium and identify areas for future inquiry. This discussion leads to a critique of the ability of the model to lead future research and practice change.

CONCLUSIONS

The Life Course Health Development Model depicts a process in which the acute and severe stress of critical illness leads to maladaptive neurologic changes that contribute to the development of delirium and impair a child's life trajectory.

RELEVANCE TO CLINICAL PRACTICE

By emphasising the potential lifelong consequences for critically ill children who experience delirium, this application of the Life Course Health Development Model will stimulate discussion, research and practice change among paediatric clinicians and researchers.

Recent evidence on early mobilization in critical-Ill patients

PURPOSE OF REVIEW

To examine the benefits of early mobilization and summarize the results of most recent clinical studies examining early mobilization in critically ill patients followed by a presentation of recent developments in the field.

RECENT FINDINGS

Early mobilization of ICU patients, defined as mobilization within 72 h of ICU admission, is still uncommon. In medical and surgical critically ill patients, mobilization is well tolerated even in intubated patients. In neurocritical care, evidence to support early mobilization is either lacking (aneurysmal subarachnoid hemorrhage), or the results are inconsistent (e.g. stroke). Successful implementation of early mobilization requires a cultural change; preferably based on an interprofessional approach with clearly defined responsibilities and including a mobilization scoring system. Although the evidence for the majority of the technical tools is still limited, the use of a bed cycle ergometer and a treadmill with strap system has been promising in smaller trials.

SUMMARY

Early mobilization is well tolerated and feasible, resulting in improved outcomes in surgical and medical ICU patients. Implementation of early mobilization can be challenging and may need a cultural change anchored in an interprofessional approach and integrated in a patient-centered bundle. Scoring systems should be integrated to define daily goals and used to verify patients' achievements or identify barriers immediately.