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Crit Care Med. 2019 Jan;47(1):3-14. doi: 10.1097/CCM.0000000000003482.

Caring for Critically Ill Patients with the ABCDEF Bundle: Results of the ICU Liberation Collaborative in Over 15,000 Adults.

Author information

1
Department of Medicine, Pulmonary and Critical Care, Critical Illness, Brain dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN.
2
The Ohio State University, College of Nursing, Columbus, OH.
3
The Ohio State University Wexner Medical Center, Columbus, OH.
4
Sutter Health, Sacramento, CA.
5
Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN.
6
Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA.
7
Stanford University School of Medicine, Stanford, CA.
8
VA Palo Alto Health Care System, Palo Alto, CA.
9
Innovative Solutions for Healthcare Education, LLC, Charlotte, NC.
10
University of North Carolina School of Medicine, Chapel Hill, NC.
11
School of Pharmacy, Northeastern University and Division of Pulmonary and Critical Care Medicine, Tufts Medical Center, Boston, MA.
12
Department of Rehabilitative Services, University of California, San Francisco, San Francisco, CA.
13
University of Chicago Medicine, Chicago, IL.
14
Houston Methodist Hospital, Houston, TX.
15
Society of Critical Care Medicine, Mount Prospect, IL.
16
Novant Health, Forsyth Medical Center, Winston-Salem, NC.
17
Saint Joseph Mercy Health System, Ann Arbor, MI.
18
Department of Physiological Nursing, School of Nursing, University of California, San Francisco, San Francisco, CA.
19
Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
20
Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN.
21
The Department of Biostatistics, Johns Hopkins University, Baltimore, MD.
22
The Tennessee Valley Veteran's Affairs Geriatric Research Education Clinical Center, Nashville, TN.

Abstract

OBJECTIVE:

Decades-old, common ICU practices including deep sedation, immobilization, and limited family access are being challenged. We endeavoured to evaluate the relationship between ABCDEF bundle performance and patient-centered outcomes in critical care.

DESIGN:

Prospective, multicenter, cohort study from a national quality improvement collaborative.

SETTING:

68 academic, community, and federal ICUs collected data during a 20-month period.

PATIENTS:

15,226 adults with at least one ICU day.

INTERVENTIONS:

We defined ABCDEF bundle performance (our main exposure) in two ways: 1) complete performance (patient received every eligible bundle element on any given day) and 2) proportional performance (percentage of eligible bundle elements performed on any given day). We explored the association between complete and proportional ABCDEF bundle performance and three sets of outcomes: patient-related (mortality, ICU and hospital discharge), symptom-related (mechanical ventilation, coma, delirium, pain, restraint use), and system-related (ICU readmission, discharge destination). All models were adjusted for a minimum of 18 a priori determined potential confounders.

MEASUREMENTS AND RESULTS:

Complete ABCDEF bundle performance was associated with lower likelihood of seven outcomes: hospital death within 7 days (adjusted hazard ratio, 0.32; CI, 0.17-0.62), next-day mechanical ventilation (adjusted odds ratio [AOR], 0.28; CI, 0.22-0.36), coma (AOR, 0.35; CI, 0.22-0.56), delirium (AOR, 0.60; CI, 0.49-0.72), physical restraint use (AOR, 0.37; CI, 0.30-0.46), ICU readmission (AOR, 0.54; CI, 0.37-0.79), and discharge to a facility other than home (AOR, 0.64; CI, 0.51-0.80). There was a consistent dose-response relationship between higher proportional bundle performance and improvements in each of the above-mentioned clinical outcomes (all p < 0.002). Significant pain was more frequently reported as bundle performance proportionally increased (p = 0.0001).

CONCLUSIONS:

ABCDEF bundle performance showed significant and clinically meaningful improvements in outcomes including survival, mechanical ventilation use, coma, delirium, restraint-free care, ICU readmissions, and post-ICU discharge disposition.

PMID:
30339549
PMCID:
PMC6298815
DOI:
10.1097/CCM.0000000000003482
[Indexed for MEDLINE]
Free PMC Article

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