AT THE CRITICAL CARE CONGRESS
ORLANDO (FRONTLINE MEDICAL NEWS) – Implementing an ICU care plan got patients moving and breathing on their own sooner. The interventions resulted in significantly less delirium and better in-hospital survival in 6,000 patients treated at seven community hospitals, according to data presented at the Critical Care Congress, sponsored by the Society for Critical Care Medicine.
The care bundle focused on minimizing sedation and maximizing patient mobilization. For each 10% increase in compliance with the care plan, community ICUs saw a 15% increase in delirium-free ICU days. In-hospital survival also increased by 15% for every 10% increase in implementation.
The ICU Liberation project set forward the ABCDEF care bundle to operationalize the Society for Critical Care Medicine (SCCM) 2012 guidelines regarding pain, agitation, and delirium in the ICU.
“It’s never quite clear whether guidelines, which are developed from randomized controlled trials in academic university hospitals, can be implemented in the community hospital setting. And as we know, the majority of critical care in our country is provided in the community hospital setting,” said Mary Ann Barnes-Daly, an RN who is the regional clinical initiative lead for ICU Liberation at Sutter Health in Sacramento, Calif.
The care bundle calls for all ICU patients to have daily assessments for pain and delirium, spontaneous awakening and breathing trials, minimal sedation, early mobilization and exercise, and family involvement as part of the care team.
A dedicated RN, whose sole responsibility was to implement the ICU Liberation program, led the on-site teams. Other team members were an administrative RN, a pharmacist, a physical therapist, a respiratory care practitioner, and an ICU physician. In some hospitals, the physician was an intensivist, while in others, a hospitalist provided ICU care.
“We provided clinical education, and more importantly, interprofessional team education, where the teams learned to work together,” said Ms. Barnes-Daly. Rounds were audited and audit results, along with ongoing data collection and reporting, were the basis for ongoing reporting and process improvement.
The mantra for care bundle implementation was “every patient, every day,” said Ms. Barnes-Daly. Patient exclusions were based on safety and included such factors as hemodynamic, respiratory, or neurologic instability; open abdomen; active alcohol withdrawal; and new coronary ischemia.
Altogether, 6,064 patients were involved in the program; about one in four patients received mechanical ventilation during their stay. When patients were mechanically ventilated, all aspects of the care bundle were to be implemented. When patients were not receiving mechanical ventilation, only four aspects of the bundle applied and were measured. Overall, patients were mechanically ventilated for about 20% of the days observed.
Compliance with the care bundle was measured in two ways, said Ms. Barnes-Daly: One analysis was all-or-none, measuring the proportion of a patient’s ICU stay for which all applicable bundle elements were implemented. The other measure allowed partial compliance; dose compliance was calculated by averaging the proportion of care bundle compliance for each day over the patient’s ICU stay. This second analysis proved more sensitive in assessing the effects of the care bundle.
A dose-response ratio was noted between the number of delirium-free and coma-free days and the number of care bundle components delivered (P less than .001). Similarly, hospital survival also increased as bundle delivery increased, with each 10% increase in compliance associated with a 15% increase in hospital survival (P less than .001). When palliative care patients were removed from data analysis, hospital survival increased by 23% with each 10% increase in bundle compliance, said Ms. Barnes-Daly.
The study’s strengths include “the large sample size, and the fact that we adjusted for age, Apache score, and mechanical ventilation,” said Ms. Barnes-Daly. The limitations are that this was not a randomized controlled trial, and data were initially collected by the nurse team leader. Data collection was subsequently switched to the electronic ICU team.
The QI program was sponsored by the Society for Critical Care Medicine, and conducted at Sutter Health community Hospitals. Ms. Barnes-Daly reported receiving honoraria from the Society for Critical Care Medicine.
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