ABCDEF Bundle Breakout Andrew Masica, MD, MSCI VP, Chief Clinical Effectiveness Officer Baylor Scott & White Health andrew.masica@bswhealth.org
Disclosures/Funding Support 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. 2
Learning Objectives 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 3
ABCDEF: A Bundle of Best Practices A B C D 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 ABCD Bundle Delirium assessment, prevention, Delirium and assessment, prevention, and management management ABCD Bundle which will be deployed across Intermountain Healthcare ABCDE Bundle Early activity and mobility F=Family Engagement
Synergy of the ABCDEF Bundle 5
ABCDEF Bundle Safety Parameters Adapted from Girard TD et al, Lancet 2008
Bundle Eligibility 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 7
ABCDEF Bundle Implementation Tactics Adoption Program Component Time to Completion Activate Nurse/ Physician Champions and secure clinical staff conceptual buy-in Assess current state (workflow, performance) Development of supportive EHR Documentation and order set with incorporation into production (live use) environment Training Sessions a. Train the trainer b. Frontline staff c. E-learning modules Use of daily rounding tool Standardized Performance Reporting (hospital and unit levels) Optimization/EHR refinement/standing meetings Accountability as a system critical care goal 1-2 months (based on hospital size) 1-month 9-12 months 4-6 month cycle to launch each unit; multiple reinforcement sessions required. 9-12 months 4 months after completion of EHR workflow tools Ongoing 3 months after standardized reporting 8
Maynard G, SHM VTE QI Resource Room, www.hospitalmedicine.org 9
Interdisciplinary Effort Identify Stakeholders Collaborative Patient Care Team VP of Medical Affairs/ CMO Hospital and Unit Directors Nursing Physicians RT PT/OT Pharmacy IT Quality Improvement Patient Safety Nursing Pharmacists Respiratory PT/OT Physicians 10 10
Automated Bundle Activation (Opt-Out Order Set) 11
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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 13
Sedation Vacation-Structured Note 5 14
Breathing Trial-Structured Note 15
Choice to use (and of) Analgesia and Sedation Sample ICU Cohort CONFIDENTIAL - Internal Use Only 16
Opioid Related ADEs: Surgical Patients (N=135,000) 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 Moderate 518.5X 997.3X 1,386 (15%) Other pulmonary insufficiency, not elsewhere classified 518.82 Bradypnea Moderate 786.09 301 (3%) Acute respiratory failure Severe 518.81 1,897 (20%) Hypoxemia 799.02 Moderate Hypoxia 977.01 1,151 (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%) Baylor Scott & White Health Proprietary and Confidential Document 17
Tests to Detect Delirium-ICU Test Description Performance Confusion Assessment Method (Long Form) Confusion Assessment Method- Intensive Care Unit (CAM-ICU) Generally used in research Bedside clinical application Adapted for Non-verbal patients Gold Standard Sensitivity-80% Specificity-96% Intensive Care Unit Delirium Screening Checklist (ICSDC) Point scoring system Sensitivity-74% Specificity-89% 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. 18
Other Delirium Tests Test Description Performance Confusion Assessment Method (Long Form) Confusion Assessment Method (Short Form) Ultrabrief Screening 3D Confusion Assessment Method Generally used in research First 4 items of full CAM Bedside clinical application Should be scored with cognitive screen 2 questions Months of year backwards What is the day of the week? Short CAM + embedded cognitive screen 3D=3 minutes, diagnostic https://www.hospitalelderlifeprogram.org/delirium-instruments/ Gold Standard Sensitivity-94% Specificity-89% Sensitivity-93% Specificity-64% Sensitivity-95% Specificity-94% 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 19
Sedation and Delirium Assessment CAM-ICU 20
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CAM-ICU Decision Support 22
Exercise/Mobility Documentation 23
It s All About Family 24
Real-Time Reporting for Measure-Vention 25
Bundle Inclusion in Team Rounds/Unit Huddles 26
Training/Education 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 27
Provider Accountability 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: A 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) B D 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) E Composite Bundle: 50-60% (1 point), 61-70% (2 points), above 70% (3 points) 28
Reporting: SAT and SBT 29
Reporting: Delirium Metrics 30
Reporting: Mobility 31
Reporting: Mobility Detail 32
Reporting: Composite Bundle 33
Interrater Reliability of CAM-ICU 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 70 85* 41 0.49 16 0.89 Hospital (0.29-0.68) Combined 66 84* 224 0.53 (0.44-0.61) *P-value <0.05 (0.69-1.00) 165 0.73 (0.64-0.81) 34
Composite Bundle Uptake by Intervention Group Maintaining at > 90% Apr-15 35
Individual Bundle Element Adherence Trends 36
Baseline Population Characteristics (by Bundle Adherence Level) 25-50% N=1004 Adherence Level 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 37
Impact on Delirium and Coma Outcomes (Risk Adjusted for Illness Severity): Comparison Group: 25%-50% Composite Bundle Adherence 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) a For patients diagnosed with delirium b For patients diagnosed with coma *p < 0.05 38
Impact on Additional Clinical Outcomes (Risk Adjusted for Illness Severity): Comparison Group: 25%-50% Composite Bundle Adherence Medium Adherence 50-75% (n = 1337) High Adherence 75-100% (n = 869) Risk-adjusted Outcomes Estimate CI Estimate CI ICU Length of Stay a 0.03 (-0.05, 0.11) 0.04 (-0.05, 0.12) Hospital Length of Stay a 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) a Patients who died during ICU stay were excluded from LOS calculations *p < 0.05 39
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 care cost reduction (i.e. 90-day costs rather than inpatient stay) 40
Questions/Discussion 41