EP12 Nurses assume leadership roles in collaborative interprofessional activities to improve the quality of care.
NAME OF INITIATIVE
ABCDE Bundle Implementation in ICU: The ABC Part
The ABCDE Bundle is a group of evidence-based interventions that can help prevent the unintended consequences of critical illness. It is endorsed by the American Association of Critical Care Nurses (AACN). It is targeted towards mechanically ventilated patients although components of it may be used for all patients. Certain elements of the bundle involve the interprofessional team, including respiratory therapists, physical therapists, pharmacists, dietitians, and physicians, among others. The components of the ABCDE Bundle are:
- ABC – Awakening and Breathing Trial Coordination. Over sedation and under sedation can lead to prolonged ventilator times among patients. This “ABC” bundle component addresses daily Spontaneous Awakening Trials (SAT) and Spontaneous Breathing Trials (SBT) to promote earlier extubation.
- D – Delirium Assessment and Management. Critically-ill patients who are susceptible to developing delirium. Unfortunately, delirium often goes undetected and untreated in scores of patients, potentially leading to a host of negative long-term consequences. This “D” bundle component addresses early identification and management of patients with delirium.
- E – Early Exercise and Progressive Mobility. Patients with prolonged bed rest or immobility are prone to developing muscle weakness and atrophy, which can lead to a longer hospital stay and long-term muscle dysfunction. This “E” bundle component provides guidance for enabling patients to become progressively more active and, possibly, walk while intubated.
In May 2012, Intensive Care Unit (ICU) Clinical Nurse Specialist (CNS) Rosemary Lee, ARNP, attended the AACN National Teaching Institute (NTI) in Orlando, Florida. Lee is a member of AACN and active on the local and national level. She has presented several poster and podium presentations during these conferences. At this particular NTI, the organization rolled out its “AACN Pearls” which was a toolkit for clinicians to implement the ABCDE Bundle.
Nurse-Led Initiative
After the conference, Lee proceeded to evaluate current ICU practice on mechanically ventilated patients in relation to the ABCDE bundle. The following is a summary of the findings based on current practice:
- Nurses did not independently initiate SAT because a physician’s order was required.
- Nurses and the respiratory therapists were unsure when to coordinate the SAT and the SBT, or whether the patient is stable enough to perform the SAT/SBT.
- Nurses did not perform routine delirium assessment.
- The interprofessional team did not follow specific guidelines on progressively mobilizing intubated patients.
Using the “AACN Roadmap for Implementing Change - ABCDE Bundle” as a guide, Lee presented the bundle to key stakeholders, namely: ICU Medical Director, Pulmonary Physician, ICU Director & Nurse Manager, Respiratory Supervisor, Clinical Pharmacist, ICU Unit Practice Council and the Rehabilitative Services Director. They all supported the implementation of the ABCDE bundle. Consequently, Lee formed an interprofessional group who performed the “AACN Unit Gap Analysis” to assess strengths and areas of opportunities.
Goal
Since there was no benchmark readily available specific to the general ICU population, the team decided to decrease the complications of critical illness by decreasing median ventilator time by 10% from baseline of 58.75 median hours to 52.87 median hours.
Median was calculated by
- Actual times of each patient on a ventilator per month: time of intubation and placement on ventilator minus time of extubation
- Each time was collated and median time in hours was calculated per month
Patients were excluded if they had any of the following:
• Limitations in care were provided (e.g. DNR/ Comfort Measure Only)
• Withdrawal of life support was done
• Patient suffered cardiopulmonary arrest within the first 24 hours of admission.
• Patients who failed traditional ventilator weaning and required tracheostomy.
• Patients who were transferred to another acute care facility.
METHODS & APPROACH
Collaborative Interprofessional Activity
The ABCDE Bundle Task Force first met on September 2012. The team initially focused on addressing and prioritizing identified gaps, specifically on the ABC component of the bundle. (EP12 01 ABCDE Bundle Task Force Meting Minutes and Sign-in Sheet 9/12/12) They revised policies & procedures to reflect this new practice. The prior policy was named “Drug Holiday Protocol” which focused on the nursing management of sedation for mechanically ventilated patients based on physician’s orders. This included basic guidelines for assessment and reassessment based on prescribed orders. The new policy (EP12 02 HH-400-2510-33 Spontaneous Awakening Trials [SAT] & Spontaneous Breathing Trials [SBT]), developed in February 2013, provided guidelines and practice changes to allow nurses and respiratory therapists to be proactive in the assessment, implementation, and evaluation of patients’ ability to begin the weaning process. It enabled ICU nurses to independently stop sedation and for respiratory therapists to initiate breathing trial if the patient met criteria for the SAT & SBT. ICU Medical Director Juan Lopetegui, MD and Pulmonary Services Medical Director Carlos Martinez, MD approved all policy and procedure changes.
Each member of this team had a pertinent role and were active participants. The Pharmacists were key in revising the Pain/ Agitation/ Delerium orders based on the most recent guidelines from the Society of Critical Care Medicine. Palliative Care Manager Linda Long, ARNP was instrumental in developing the education programs for the Richmond Agitation Sedation Scale (RASS) and the Confusion Assessment Method for ICU (CAM-ICU). She assisted with the inservices as well as bedside learning and discussions during interdisciplinary rounds. She collaborated with the Pharmacists on the Pain/ Agitation/ Delirium orders. The Respiratory Therapists and Nurses collaborated on refining the screens for the SAT and SBT. They also discussed how to partner with each other to coordinate the SAT & SBT. They worked together in revising policies and procedures. The dietitians’ concern was that the patient be adequately nourished within 48 hours of being on a ventilator. They identified areas that could be improved, which led to the development of another team that looked into improving the nutritional support of the ICU patient. The Physical Therapists were key in refining the mobility screening and clarifying their role in the process. (EP12 03 ABCDE Bundle Task Force Meting Minutes and Sign-in Sheet 11/1412 and 12/12/12)
From February to April 2013, Lee, Clinical Nurse Joyce Nealey, RN and Long educated the ICU nursing staff on the evidence, policy & procedure and expectations regarding SAT and SBT. Lee conducted the education after staff meetings and scheduled additional in-services that covered various shifts. Respiratory Nurse Educator Edda Avila, RN, RRT provided the education to the respiratory care providers and incorporated it in their annual competency validation. (EP12 04 In-Service Sign-in Sheet and Respiratory Competency Assessment) Thereafter, the task force implemented the ABC portion of the bundle on April 15, 2013.
PARTICIPANTS
The members of the interprofessional ABCDE Bundle Task Force were as follows:
Name/Credentials |
Title |
Department |
Role in the Team |
Rosemary Lee, DNP, ARNP-BC, CCNS, CCRN |
Clinical Nurse Specialist |
Critical Care |
Chair |
Joyce Nealey, RN |
Clinical Nurse |
Critical Care |
Member |
Tashi Benjamin, RN |
Clinical Nurse |
Critical Care |
Member |
Onyinye Anyakudo, BSN, RN |
Clinical Nurse |
Critical Care |
Member |
LaQuinta Roberts, RN, CCRN |
Clinical Nurse |
Critical Care |
Member |
Liriola Harrison, BSN RN, |
Patient Care Supervisor |
Critical Care |
Member |
Nina Espino, MSN, RN, CCRN |
Patient Care Supervisor |
Critical Care |
Member |
Leslie Everett, BSN, RN, CCRN |
Patient Care Manager |
Critical Care |
Member, Critical Care Leadership Support |
Ana Cabrera, DNP, ARNP, ANP-BC, CCRN, NEA-BC |
Assistant Vice President of Nursing |
Nursing Administration |
Executive Sponsor |
Linda Long, MSN, ARNP-BC, GNP-BC, CHPN |
Manager |
Palliative Care |
Member |
Eda Avila BSN, RN, CRRT |
Clinical Nurse Educator |
Respiratory Therapy |
Member; provided education to respiratory therapists |
Tatiana Ortiz, RD |
Dietitian |
Dietary Services |
Member |
Mary Shaw, RD |
Dietitian |
Dietary Services |
Member |
Suzanne Lopez |
Physical Therapist |
Rehabilitation Services |
Member |
Michelle Sinclair |
Physical Therapist |
Rehabilitation Services |
Member |
Christopher Freeman, RRT |
Respiratory Therapist |
Respiratory Therapy |
Member |
Rollene Price, RRT |
Supervisor |
Respiratory Therapy |
Member, Respiratory Leadership Support |
Winifred Pardo, PharmD |
Clinical Pharmacist |
Pharmacy |
Member, review of sedation and analgesic agents |
Juan Lopetegui, MD |
Medical Director |
Critical Care |
Physician Champion |
Carlos Martinez, MD |
Medical Director |
Pulmonary Services |
Physician Supporter |
OUTCOME(S)
Utilizing the Kirkpatrick’s 4 Level Evaluation Model as framework, the team evaluated the education program as follows:
- Step 1: Reaction – The overall reaction of the staff was positive. Initially, they were hesitant about implementing SAT and SBT without a written physician order. Lopetegui and Martinez provided encouragement to the staff, which enabled them to move forward.
- Step 2: Learning – Lee reviewed clinical nurses’ documentation through chart checks for accuracy in calculating the RASS and provided feedback.
- Step 3: Behavior - The team observed the clinical nurses using the RASS score more consistently during the daily interprofessional rounds.
- Step 4: Results – See Exhibit EP12a below.
EP12a: Median Ventilator Hours of ABC Awakening and Breathing Trial Coordination in ICU
Analysis: Above graph depicts a significant decrease in the median hours on the ventilator post-intervention. In August 2013, the team noted a spike in the data. Upon review, they discovered that this increase was related to several high acuity patients with prolonged ICU stay and overall hospitalization. In the succeeding months, the average median time once again declined to 26.62 hours, a 45% decrease from the pre-implementation numbers.
Summary Attachments/Hyperlinks/Evidences
EP12 01 ABCDE Bundle Task Force Meting Minutes and Sign-in Sheet 9/12/12
EP12 02 HH-400-2510-33 Spontaneous Awakening Trials [SAT] & Spontaneous Breathing Trials [SBT]
EP12 03 ABCDE Bundle Task Force Meting Minutes and Sign-in Sheet 11/1412 and 12/12/12
EP12 04 In-Service Sign-in Sheet and Respiratory Competency Assessment
EP12a: Median Ventilator Hours of ABC Awakening and Breathing Trial Coordination in ICU