TY - JOUR
T1 - Implementing the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle into everyday care
T2 - Opportunities, challenges, and lessons learned for implementing the ICU pain, agitation, and delirium guidelines
AU - Balas, Michele C.
AU - Burke, William J.
AU - Gannon, David E
AU - Cohen, Marlene Z.
AU - Colburn, Lois
AU - Bevil, Catherine
AU - Franz, Doug
AU - Olsen, Keith M.
AU - Wesley Ely, E.
AU - Vasilevskis, Eduard E.
PY - 2013
Y1 - 2013
N2 - Objective: The awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle is an evidence-based interprofessional multicomponent strategy for minimizing sedative exposure, reducing duration of mechanical ventilation, and managing ICU-acquired delirium and weakness. The purpose of this study was to identify facilitators and barriers to awakening and breathing coordination, delirium monitoring/ management, and early exercise/mobility bundle adoption and to evaluate the extent to which bundle implementation was effective, sustainable, and conducive to dissemination. Design: Prospective, before-after, mixed-methods study. Setting: Five adult ICUs, one step-down unit, and a special care unit located in a 624-bed academic medical center SUBJECTS:: Interprofessional ICU team members at participating institution. INTERVENTIONS AND MEASUREMENTS:: In collaboration with the participating institution, we developed, implemented, and refined an awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle policy. Over the course of an 18-month period, all ICU team members were offered the opportunity to participate in numerous multimodal educational efforts. Three focus group sessions, three online surveys, and one educational evaluation were administered in an attempt to identify facilitators and barriers to bundle adoption. MAIN Results: Factors believed to facilitate bundle implementation included: 1) the performance of daily, interdisciplinary, rounds; 2) engagement of key implementation leaders; 3) sustained and diverse educational efforts; and 4) the bundle's quality and strength. Barriers identified included: 1) intervention-related issues (e.g., timing of trials, fear of adverse events), 2) communication and care coordination challenges, 3) knowledge deficits, 4) workload concerns, and 5) documentation burden. Despite these challenges, participants believed implementation ultimately benefited patients, improved interdisciplinary communication, and empowered nurses and other ICU team members. Conclusions: In this study of the implementation of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle in a tertiary care setting, clear factors were identified that both advanced and impeded adoption of this complex intervention that requires interprofessional education, coordination, and cooperation. Focusing on these factors preemptively should enable a more effective and lasting implementation of the bundle and better care for critically ill patients. Lessons learned from this study will also help healthcare providers optimize implementation of the recent ICU pain, agitation, and delirium guidelines, which has many similarities but also some important differences as compared with the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle.
AB - Objective: The awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle is an evidence-based interprofessional multicomponent strategy for minimizing sedative exposure, reducing duration of mechanical ventilation, and managing ICU-acquired delirium and weakness. The purpose of this study was to identify facilitators and barriers to awakening and breathing coordination, delirium monitoring/ management, and early exercise/mobility bundle adoption and to evaluate the extent to which bundle implementation was effective, sustainable, and conducive to dissemination. Design: Prospective, before-after, mixed-methods study. Setting: Five adult ICUs, one step-down unit, and a special care unit located in a 624-bed academic medical center SUBJECTS:: Interprofessional ICU team members at participating institution. INTERVENTIONS AND MEASUREMENTS:: In collaboration with the participating institution, we developed, implemented, and refined an awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle policy. Over the course of an 18-month period, all ICU team members were offered the opportunity to participate in numerous multimodal educational efforts. Three focus group sessions, three online surveys, and one educational evaluation were administered in an attempt to identify facilitators and barriers to bundle adoption. MAIN Results: Factors believed to facilitate bundle implementation included: 1) the performance of daily, interdisciplinary, rounds; 2) engagement of key implementation leaders; 3) sustained and diverse educational efforts; and 4) the bundle's quality and strength. Barriers identified included: 1) intervention-related issues (e.g., timing of trials, fear of adverse events), 2) communication and care coordination challenges, 3) knowledge deficits, 4) workload concerns, and 5) documentation burden. Despite these challenges, participants believed implementation ultimately benefited patients, improved interdisciplinary communication, and empowered nurses and other ICU team members. Conclusions: In this study of the implementation of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle in a tertiary care setting, clear factors were identified that both advanced and impeded adoption of this complex intervention that requires interprofessional education, coordination, and cooperation. Focusing on these factors preemptively should enable a more effective and lasting implementation of the bundle and better care for critically ill patients. Lessons learned from this study will also help healthcare providers optimize implementation of the recent ICU pain, agitation, and delirium guidelines, which has many similarities but also some important differences as compared with the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle.
KW - and early exercise/mobility bundle
KW - awakening and breathing coordination
KW - delirium
KW - delirium monitoring/management
KW - immobility
KW - implementation research
KW - intensive care unit
KW - interprofessional
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UR - http://www.scopus.com/inward/citedby.url?scp=84883592428&partnerID=8YFLogxK
U2 - 10.1097/CCM.0b013e3182a17064
DO - 10.1097/CCM.0b013e3182a17064
M3 - Article
C2 - 23989089
AN - SCOPUS:84883592428
SN - 0090-3493
VL - 41
SP - S116-S127
JO - Critical care medicine
JF - Critical care medicine
IS - 9 SUPPL.1
ER -