ABCDEF Bundle Breakout

Andrew Masica, MD, MSCIVP, Chief Clinical Effectiveness Officer

Baylor Scott & White Health

andrew.masica@BSWHealth.org

Disclosures/Funding Support

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Grant R18-HS021459 from the Agency for Healthcare Research and Quality (AHRQ) funded portions of this work. The findings and conclusions in this program are those of the author, who is responsible for its content, and do not necessarily represent the views of AHRQ.

Baylor Scott & White Research institute holds research grants from the following companies on which Dr. Masica is an investigator: Pfizer, Mallinckrodt, Medtronic.

These research grants are unrelated to the presentation content. No commercial products or services will be referenced.

Learning Objectives

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1. Articulate ABCDEF bundle care processes, eligibility criteria, and safety parameters

2. Delineate specific EHR workflows to facilitate ABCDEF Bundle adoption and reliable use by front-line staff

3. Interpret and apply ABCDEF reports to help guide ICU quality improvement efforts

ABCDEF: A Bundle of Best Practices

ABCD Bundle

Delirium assessment, prevention,

and management

ABCD Bundle which will be deployed across Intermountain Healthcare

E

Assess for, prevent, and manage pain

Both spontaneous

awakening trial (SAT)

and spontaneous

breathing (SBT) trial

Choice to use (and of)

analgesia and sedation

Delirium assessment, prevention,

and management

Early activity and mobility

E

ABCDE Bundle

DCBA

F=Family Engagement

Synergy of the ABCDEF Bundle

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ABCDEF Bundle Safety Parameters

Adapted from Girard TD et al, Lancet 2008

Bundle Eligibility

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• Inclusion Criteria– 18 years of age or older– ICU admission lasting >24 hours– On the ventilator for >48 hours and <14 days

• Exclusion Criteria– On comfort/hospice care– Pending transfer to non-ICU bed– Never on the ventilator– Physician opt-out

Bundle currently used across all ICU-types/specialties

ABCDEF Bundle Implementation TacticsAdoption Program Component Time to Completion

Activate Nurse/ Physician Champions and secure clinical staff conceptual buy-in

1-2 months (based on hospital size)

Assess current state (workflow, performance) 1-month

Development of supportive EHR Documentation and order set with incorporation into production (live use) environment

9-12 months

Training Sessionsa. “Train the trainer”b. Frontline staffc. E-learning modules

4-6 month cycle to launch each unit; multiple “reinforcement” sessions required.

Use of daily rounding tool 9-12 months

Standardized Performance Reporting (hospital and unit levels)

4 months after completion of EHR workflow tools

Optimization/EHR refinement/standing meetings Ongoing

Accountability as a system critical care goal 3 months after standardized reporting

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Maynard G, SHM VTE QI Resource Room, www.hospitalmedicine.org

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Identify Stakeholders

VP of Medical Affairs/ CMO

Hospital and Unit Directors

Nursing

Physicians

RT

PT/OT

Pharmacy

IT

Quality Improvement

Patient Safety

Collaborative Patient Care Team

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Interdisciplinary Effort

Respiratory

PT/OT

Physicians

Nursing

Pharmacists

Automated Bundle Activation

(Opt-Out Order Set)

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Assess for, Prevent and Manage Pain

• CPOT for intubated patients• Pain Intensity Scale for verbal patients• Assessments every 2 hours for ICU level care

Sedation Vacation-Structured Note

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5

Breathing Trial-Structured Note

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CONFIDENTIAL - Internal Use Only 16

Choice to use (and of) Analgesia and Sedation

Sample ICU Cohort

Opioid Related ADEs: Surgical Patients(N=135,000)

17Baylor Scott & White Health – Proprietary and Confidential Document

ORADE Descriptions Severity ICD9 Codes N (%)

Respiratory 9,437 (49%)

Pulmonary congestion & hypostasis Mild 514 172 (2%)

Pulmonary insufficiency following surgery and trauma

Respiratory complications

Other pulmonary insufficiency, not elsewhere classified

Moderate

518.5X

997.3X

518.82

1,386 (15%)

Bradypnea Moderate 786.09 301 (3%)

Acute respiratory failure Severe 518.81 1,897 (20%)

Hypoxemia

HypoxiaModerate

799.02

977.011,151 (13%)

Mechanical ventilator Severe 96.7X 4,530 (48%)

Central Nervous System 1,431 (7%)

Delirium

Altered mental status

Confusion – classified otherwise

Moderate

780.09

780.97

293.xx

1,426 (99%)

Nervousness Mild 799.2X 4 (<1%)

Dizziness/vertigo Mild 386.2 1 (<1%)

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Test Description Performance

Confusion Assessment Method(Long Form)

Generally used in research Gold Standard

Confusion Assessment Method-Intensive Care Unit (CAM-ICU)

Bedside clinical applicationAdapted for Non-verbal patients

Sensitivity-80%Specificity-96%

Intensive Care Unit Delirium Screening Checklist (ICSDC)

Point scoring system Sensitivity-74%Specificity-89%

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Tests to Detect Delirium-ICU

Gusmao-Flores D et al. The confusion assessment method for the intensive care unit (CAM-ICU) and intensive care delirium screening checklist (ICDSC) for the diagnosis of delirium: a systematic review and meta-analysis of clinical studies. Critical Care 2012 16:R115.

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Test Description Performance

Confusion Assessment Method(Long Form)

Generally used in research Gold Standard

Confusion Assessment Method(Short Form)

First 4 items of full CAMBedside clinical applicationShould be scored with cognitive screen

Sensitivity-94%Specificity-89%

Ultrabrief Screening 2 questions“Months of year backwards”“What is the day of the week?”

Sensitivity-93%Specificity-64%

3D Confusion Assessment Method Short CAM + embedded cognitive screen3D=3 minutes, diagnostic

Sensitivity-95%Specificity-94%

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Other Delirium Tests

https://www.hospitalelderlifeprogram.org/delirium-instruments/

Fick et al, Preliminary Development of an Ultrabrief Two-Item Bedside Test for Delirium, J Hosp Med 2015

Kuczmarka et al, Detection of Delirium in Hospitalized Older General Medicine Patients: A Comparison of the 3D-CAMand CAM-ICU, J Gen Intern Med 2015

Sedation and Delirium AssessmentCAM-ICU

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CAM-ICU Decision Support

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Exercise/Mobility Documentation

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It’s All About Family

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Real-Time Reporting for “Measure-Vention”

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Bundle Inclusion in Team Rounds/Unit Huddles

Training/Education

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“Super-trainer” course:

Capability of teaching peers in CAM-ICU (including teach-back)

High degree of acumen with EHR changes

Case studies

Basic course for frontline staff:

Understand components of the ABCDE bundle and ways to incorporate those processes into routine clinical care

Identify potential barriers and facilitators to implementation of the ABCDE bundle

Become comfortable with bundle related changes in the EHR

Development of e-learning modules

Provider Accountability

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Goal: For ICU patients with acute respiratory failure requiring mechanical ventilation for ≥ 24 hours, adherence to specific components of the ventilator management bundle (daily awakening trials, spontaneous breathing trials, delirium screening, early mobility). The denominator will be based on the # of observations for which the patient is eligible (i.e. had an appropriate indication and met safety criteria to receive that process) on a daily basis. Observations after > 14 days on mechanical ventilation will be excluded. Points assigned for process performance levels and added cumulatively.

Performance Targets:

Daily Awakening Trial: 60-70% (1 point); 71-80% (2 points), above 80% (3 points)

Breathing Trials: 60-70% (1 point); 71-80% (2 points); above 80% (3 points)

Delirium Screening: 70-80% (1 point), 81-90% (2 points); above 90% (3 points)

Exercise/Mobility: 50-60% (1 point); 61-70% (2 points); above 70% (3 points)

Composite Bundle: 50-60% (1 point), 61-70% (2 points), above 70% (3 points)

D

E

B

A

Reporting: SAT and SBT

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Reporting: Delirium Metrics

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Reporting: Mobility

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Reporting: Mobility Detail

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Reporting: Composite Bundle

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Interrater Reliability of CAM-ICU

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Performance of CAM-ICU in Eligible Patients Inter-rater Reliability of CAM-ICU

Pre Post Pre Post

Patients with documented

CAM-ICU (%)

Patients with documented

CAM-ICU (%)

Paired cases

N

Kappa Coefficient (95% CI)

Paired cases

N

Kappa Coefficient (95% CI)

Tertiary Hospital

65 84* 183 0.53 (0.43-0.63)

149 0.71 (0.62-0.80)

Community Hospital

70 85* 41 0.49 (0.29-0.68)

16 0.89 (0.69-1.00)

Combined 66 84* 224 0.53 (0.44-0.61)

165 0.73 (0.64-0.81)

*P-value <0.05

Composite Bundle Uptake by Intervention Group

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Apr-15

Maintaining at > 90%

Individual Bundle Element Adherence Trends

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Baseline Population Characteristics(by Bundle Adherence Level)

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Adherence Level

25-50%

N=1004

50-75%

N=1539

75-100%

N=1317

p-value

Age, mean (SD) 61.77 (15.21) 60.56 (15.47) 60.19 (15.64) 0.0562

Gender (male), n (%) 460 (51) 523 (58) 504 (55) 0.0046*

Race, n (%)

White 605 (67) 926 (66) 877 (71) 0.0106*

Black 252 (28) 418 (30) 308 (25)

Other 50 (6) 60 (5) 54 (5)

Hispanic n (%) 127 (14) 108 (11) 114 (13) 0.3283

Insurance, n (%)

Private 111 (12) 205 (15) 182 (15) 0.1736

Medicare 501 (55) 742 (53) 612 (49)

Medicaid 51 (6) 72 (5) 61 (5)

Other 244 (26) 385 (26) 386 (27)

APACHE Score, mean (SD) 19.12 (6.73) 18.27 (6.29) 18.03 (6.43) 0.0004*

Charlson Comorbidity Index, mean (SD) 5.06 (2.86) 4.70 (2.75) 4.51 (2.78) <.0001*

APR DRG Severity, n (%)

3 68 (8) 162 (12) 192 (15) <.0001*

4 837 (92) 1233 (88) 1026 (83)

APR-DRG Mortality Risk, n (%)

3 129 (14) 308 (22) 359 (29) <.0001*

4 762 (84) 1057 (75) 838 (68)

Surgical, n (%) 94 (10) 166 (18) 161 (18) <.0001*

Dementia, n (%) 70 (8) 63 (7) 61 (7) 0.6833

Alcohol, n (%) 21 (2) 23 (2) 17 (2) 0.3473

Current Smoker, n (%) 172 (19) 187 (21) 193 (21) 0.3926

Impact on Delirium and Coma Outcomes(Risk Adjusted for Illness Severity):

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Medium Adherence

50-75%

(n = 1337)

High Adherence

75-100%

(n = 869)

Risk-adjusted Outcomes Estimate CI Estimate CI

Incidence of delirium (OR) 1.49* (1.21, 1.84) 1.73* (1.37, 2.18)

Duration of delirium (days)a 0.10 (-0.08, 0.29) 0.23 (-0.04, 0.50)

Incidence of coma (OR) 0.67* (0.51, 0.88) 0.53* (0.40, 0.71)

Duration of coma (days)b -0.32* (-0.37, -0.27) -0.52* (-0.72, -0.33)

% Coma/delirium free days 0.18* (0.13, 0.23) 0.23* (0.13, 0.33)

Comparison Group: 25%-50% Composite Bundle Adherence

aFor patients diagnosed with deliriumbFor patients diagnosed with coma

*p < 0.05

Impact on Additional Clinical Outcomes(Risk Adjusted for Illness Severity):

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Medium Adherence

50-75%

(n = 1337)

High Adherence

75-100%

(n = 869)

Risk-adjusted Outcomes Estimate CI Estimate CI

ICU Length of Staya 0.03 (-0.05, 0.11) 0.04 (-0.05, 0.12)

Hospital Length of Staya 0.00 (-0.04, 0.03) -0.03 (-0.08, 0.03)

Ventilator days -0.05 (-0.14, 0.03) -0.20* (-0.36, -0.05)

Mobilized out of bed (OR) 2.49* (1.97, 3.15) 3.97* (3.05, 5.16)

Discharged home (OR) 1.76* (1.41, 2.21) 2.16* (1.69, 2.75)

Inpatient mortality (OR) 0.39* (0.31, 0.48) 0.25* (0.19, 0.31)

Comparison Group: 25%-50% Composite Bundle Adherence

aPatients who died during ICU stay were excluded from LOS calculations

*p < 0.05

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Bundle Program Clinical Implications

Higher use of the ABCDEF bundle across a “real-world” setting (multiple hospitals in a heterogeneous delivery organization) was associated with improvements in several patient-centered outcomes.

Deployment of the bundle likely unmasks cases of “hidden” ICU delirium rather than a true incidence increase; % of days awake without delirium increased with higher adherence levels.

We have observed ongoing opportunities to improve physician response to recognized cases of delirium and with mobilization.

The bundle is gaining momentum as a patient safety practice; several collaboratives to promote adoption are underway.

The financial savings may accrue more from reduced post-acute carecost reduction (i.e. 90-day costs rather than inpatient stay)

Questions/Discussion

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