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Massachusetts General Hospital

(MGH) Collaborate to Extubate:

A Needs Assessment and Educational Program

on the ABCDEF Bundle

Erica Edwards, RN, MSN, CCRN-CMC, CHFN Lisa O’Neill, RN, BSN

Norine O’Malley-Simmler, RN, BSN Alicia Sheehan, RN, BSN

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Collaborate to Extubate Project

Goal

To assess intensive care nurses’ knowledge of the ABCDEF Bundle at MGH and provide education to address gaps in knowledge.

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What Is the ABCDEF Bundle?

 The ABCDEF bundle is a coordinated effort between

multiple disciplines for the management of patients who are ventilated help prevent the unintended consequences of critical illness.

 The aim of using the bundle is to reduce oversedation, immobility and the development of delirium in patients who are ventilated thereby reducing ventilator days (VD) and length of stay (LOS).

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What Does ABCDEF Stand For?

ABC–Awakening and Breathing Trial Coordination/

Collaboration

 Addresses daily Spontaneous Awakening Trials (SATs) (sedation vacation) and Spontaneous Breathing Trials (SBTs) to promote earlier extubation

 C also represents the Choice of sedation to be used

D–Delirium Assessment and Management

 Addresses early identification and management of patients with delirium

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ABCDEF (continued)

E–Early Exercise and Progressive Mobility

 Provides guidance for enabling patients to become progressively more active and, possibly, walk while intubated

And…

F–Family Involvement

 Involving the family in all aspects of the bundle to assist and support the patient

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Families

Built on the work done in the MGH CICU around family presence during resuscitation and other procedures.

Families provide active presence, serving as protectors, facilitators, and historians. They can act as coaches as patients are weaned from ventilators and help with early mobility.1-2

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Significance: Scope of the Problem

There were 790,257 hospitalizations involving mechanical ventilation in the U.S. in 2005.

The estimated national cost was $27 billion, or 12% of all hospital costs.

Mortality for patients who are mechanically ventilated is high.

Quality improvement and cost reduction strategies are warranted when caring for these patients.

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Impact of Implementing

Bundle on Health Care

Decreased VD and LOS

Implementing daily spontaneous awakening trials3

 Ventilator days (VD)- ↓ 2.4 days

 Length of stay (LOS)- ↓ 3.5 days

Using non-benzodiazepine vs benzodiazepine sedation4

 VD ↓ 1.9 days

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Impact of implementing bundle on

healthcare – decreased ventilator days

and length of stay

 Implementing daily spontaneous awakening trials:² Ventilator days - ↓ 2.4 days

LOS - ↓ 3.5 days

 Using non-Benzodiazepines vs. Benzodiazepines sedation³ Ventilator days - ↓ 1.9 days

LOS - ↓ 1.62 days

2 Rose, Louise; Maunder, Robert; Hunter, Jon, et al. Sleep, cognitive, and psychological morbidity following sedation protocol and daily sedative interruption vs. sedation protocol alone in critically ill, mechanically ventilated adults (SLEAP-SCP). CCM .2012: 40(12) p 1–328

³Fraser, G.L., Devlin, J.W., Worby, C.P. et al. Benzodiazepine versus nonbenzodiazapine –based sedation for mechanically ventilated , critically ill adults: a systematic review and meta-analysis of randomized trials. CCM 2013; 41(9), p 30-8

Impact of Implementing

Bundle on Health Care

Decreased VD and LOS

Early mobility of patients on ventilators5

 LOS in the ICU ↓ 1.4 days

 LOS in the hospital ↓ 3.3 days

Delirium detection and prevention6

 LOS ↓ 3.6 days

 Incidence of delirium ↓ 1.6%

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Projected Cost Savings of

Implementation of the ABCDEF Bundle

Cost savings (from national averages)5,7-8

SATs

 VD 2.4 x $1,522 (1 VD)= $3,652

 LOS 3.3 x $3,500 (1 ICU day) = $11,550

Early Mobility

 LOS in hospital = $18,544.80 in 1 month

Delirium

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Project Logo and Catch Phrase:

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Study Design

 Convenience sample of nurses working in all areas at MGH that

have patients who are ventilated

 Survey design adapted from AACN Pearl: Implementing the ABCDE

Bundle at the Bedside and unit gap analysis to assess:

 Communication and collaboration

 Sedation awakening/spontaneous breathing trial/coordination and choice of sedation

 Delirium

 Early exercise

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Data Collection Procedure

IRB approval per MGH policy

Met with nurse directors and CNSs of ICUs for approval and permission to send survey to staff

Survey sent via Qualtrics

Emailed weekly survey reminders

Used posters and offered candy in snowman-decorated boxes to remind staff to take survey

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Demographics

N = 212 respondents

How many years as a nurse?

 Mean = 14.4 + 11.34

Highest level of nursing education

 AD: 9%, BSN: 79.7%, MSN: 9.9%, Doctorate: 0.9%

CCRN certification

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Demographics

Which unit do you work on?

 Blake 12 ICU: 10.8%

 Burn ICU (Bigelow 13): 2.8%

 Cardiac ICU (Ellison 9): 14.6%

 Cardiac Surgical ICU (Blake 8): 5.7%

 Medical ICU (Blake 7): 15.6%

 Neuroscience ICU (Lunder 6): 18.4%

 PICU: 4.7%

 RACU (Bigleow 9): 8.5%

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Survey Results

Communication and Collaboration10 Yes/

Always

No/ Never Every nurse on our unit embraces true

collaboration as an ongoing process and invests in its development to ensure a sustained culture of collaboration.

89.5% 10.5%

Every nurse contributes to the achievement of

common unit goals. 90.4% 9.6%

All staff nurses are informed and knowledgeable about patient outcomes and performance

improvement data for our unit.

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Survey Results

Sedation Awakening Trial/ Spontaneous Breathing Trial/ Coordination and Choice of Sedation

Yes/ Always

No/ Never Our unit has a sedation and analgesia protocol in

place. 72.2% 27.8%

The nurses routinely perform both a pain and

sedation assessment on patients, using a validated tool.

91% 9%

Our nurses currently perform Spontaneous

Awakening Trials (SATs, aka “sedation vacations”) daily on all patients receiving sedation.

72.3% 27.7%

We have a standardized protocol for performing

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Survey Results

Delirium Assessment and Management Yes/

Always

No/ Never All patients are assessed daily for the presence of

delirium. 69.5% 30.5%

Our nurses use a validated tool to assess for the presence of delirium (CAM-ICU, ICDSC, pCAM-ICU).

46.9% 53.1%

Our nurses have a standardized delirium

management protocol. 24.5% 75.5%

Delirium monitoring is included in our daily

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Survey Results

Early Exercise and Progressive Mobility Yes/

Always

No/ Never Our nurses have a protocol for early exercise and

progressive mobility for patients. 67.5% 32.5%

Immobile patients on our unit receive passive

range of motion regularly, if tolerated. 62.2% 37.8%

Our nurses have the necessary support equipment

to safely assist with patients’ increased mobility. 78.4% 21.6% Respiratory therapists and physical therapists are

available to assist with implementing early exercise and progressive mobility protocols.

83% 17%

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Survey Results

Family Involvement Yes/

Always

No/ Never Our nurses provide a family-centered philosophy

of care that supports visitations. 99% 1%

Families are encouraged to give their input and

ask questions. 97.1% 2.9%

Family support and participation in all aspects of

patient care are encouraged. 88.7% 11.3%

Our nurses recognize the importance of updating families daily regarding their loved one’s

condition.

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Hospital Fiscal Savings

VD and LOS

Reduction in VD by 1.21% (50 days/quarter)

Projected cost savings per quarter: $76,100

 50 VD x $1,522 (average cost/VD)7

Projected annual savings =

$305,600

 $76,400 x 4 quarters

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Educational Intervention

 Live educational sessions on each unit, 1 on day shift and 1 during evening (with 2 repeated for a total of 20 live sessions)

 Assessed current practice with each unit’s specific patient population

 Celebrated practices that were already in place and educated staff on other parts of bundle

 HealthStream PowerPoint slides

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Education - Best Practices

CAM-ICU and P-CAM ICU delirium assessment tools

SAT/SBT and mobility protocols

Delirium prevention strategies – “Give PEACE a Chance”

Physiologic, Environmental, ADLs/Sleep, Communication,

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Future Directions

Met with Dr. Perrin Cobb (Director of the Massachusetts General Hospital Critical Care Center and Vice Chair for

Critical Care in the Department of Anesthesia, Critical Care and Pain Medicine) about CSI project. He recently

presented the ABCDE bundle in a critical care grand rounds.

 MGH CSI Team has been invited to take part in hospital-wide implementation.

Widespread use of CAM-ICU delirium assessment

Mobility protocols

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Special Thanks

 AACN CSI Faculty: Dave Hanson, MSN, RN, CNS, NEA-BC

 Chief Nurse and Senior Vice President for Patient Care at MGH: Jeanette Ives Erickson, RN, DNP, FAAN

MGH Coaches: Colleen K. Snydeman, RN, PhDc, NE-BC and Susan Stengrevics, RN, MSN, ACNS-BC, CCRN

 MGH Norman Knight Nursing Center for Clinical and Professional Development: Kathryn Larivee, RN, MSN

 MGH Yvonne Munn Center for Nursing Research: Dorothy Jones, EdD, FAAN; Mary Duffy, RN, PhD; Susan Lee, RN, PhD; and Jane Flanagan, PhD, ANP-BC

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References

1. Edwards EE, Despotopulos LD, Carroll DL. Changes in provider perceptions of family presence during resuscitation. Clin Nurse Spec. 2013;27(5):239-244.

2. Rukstele CD, Gagnon MM. Making strides in preventing ICU-acquired weakness: involving family in early progressive mobility. Crit Care Nurs Q. 2013;36(1):141-147.

3. Rose L, Maunder R, Hunter J, et al. Sleep, cognitive and psychological morbidity following sedation protocol and daily sedative interruption vs sedation protocol alone in critically ill, mechanically ventilated adults (SLEAP-SCP). Crit Care Med. 2012;40(12suppl 1):1-328. 4. Fraser GL, Devlin JW, Worby CP, et al. Benzodiazepine versus nonbenzodiazapine–based

sedation for mechanically ventilated, critically ill adults: a systematic review and meta-analysis of randomized trials. Crit Care Med. 2013;41(9suppl1):S30-S38.

5. Morris PE, Goad A, Thompson C, et al. Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med. 2008;36(8):2238-2243.

6. Allen KR, Fosnight SM, Wilford R, et al. Implementation of a system-wide quality

improvement project to prevent delirium in hospitalized patients. Jclin Outcomes Manage. 2011;18(6):253-258.

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References

7. Dasta JF, McLaughlin TP, Mody SH, Piech CT. Daily cost of an intensive care unit day: the contribution of mechanical ventilation. Crit Care Med. 2005;33(6):1266-1271.

8. King L. Developing a progressive mobility activity protocol. Orthop Nurs. 2012;31(5):253-262.

9. Research Triangle Institute for Center for Medicare & Medicaid Services. Analysis report: Estimating the incremental costs of hospital-acquired conditions (HACs). 2012.

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/index.html. Accessed April 1, 2014. (Click Incremental Updated Cost Report).

10. American Association of Critical-Care Nurses. AACN standards for establishing and sustaining healthy work environments: a journey to excellence. 2005.

http://www.aacn.org/WD/HWE/Docs/HWEStandards.pdf. Accessed April 18, 2012. 11. Balas MC, Rice M, Chaperon C, Smith H, Disbot M, Fuchs B. Management of delirium in