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Massachusetts General Hospital
(MGH) Collaborate to Extubate:
A Needs Assessment and Educational Program
on the ABCDEF Bundle
Erica Edwards, RN, MSN, CCRN-CMC, CHFN
Lisa O’Neill, RN, BSN
Norine O’Malley-Simmler, RN, BSN
Alicia Sheehan, RN, BSN
Collaborate to Extubate Project
Goal
 To assess intensive care nurses’ knowledge of the ABCDEF
Bundle at MGH and provide education to address gaps in
knowledge.
What Is the ABCDEF Bundle?
 The ABCDEF bundle is a coordinated effort between
multiple disciplines for the management of patients who
are ventilated help prevent the unintended consequences
of critical illness.
 The aim of using the bundle is to reduce oversedation,
immobility and the development of delirium in patients
who are ventilated thereby reducing ventilator days (VD)
and length of stay (LOS).
What Does ABCDEF Stand For?
 ABC–Awakening and Breathing Trial Coordination/
Collaboration
 Addresses daily Spontaneous Awakening Trials (SATs) (sedation
vacation) and Spontaneous Breathing Trials (SBTs) to promote
earlier extubation
 C also represents the Choice of sedation to be used
 D–Delirium Assessment and Management
 Addresses early identification and management of patients with
delirium
ABCDEF (continued)
 E–Early Exercise and Progressive Mobility
 Provides guidance for enabling patients to become progressively
more active and, possibly, walk while intubated
And…
 F–Family Involvement
 Involving the family in all aspects of the bundle to assist and
support the patient
Families
 Built on the work done in the MGH CICU around family
presence during resuscitation and other procedures.
 Families provide active presence, serving as protectors,
facilitators, and historians. They can act as coaches as
patients are weaned from ventilators and help with early
mobility.1-2
Significance: Scope of the Problem
 There were 790,257 hospitalizations involving mechanical
ventilation in the U.S. in 2005.
 The estimated national cost was $27 billion, or 12% of all
hospital costs.
 Mortality for patients who are mechanically ventilated is
high.
 Quality improvement and cost reduction strategies are
warranted when caring for these patients.
Impact of Implementing
Bundle on Health Care
Decreased VD and LOS
 Implementing daily spontaneous awakening trials3
 Ventilator days (VD)- ↓ 2.4 days
 Length of stay (LOS)- ↓ 3.5 days
 Using non-benzodiazepine vs benzodiazepine sedation4
 VD ↓ 1.9 days
 LOS ↓ 1.62 days
Impact of implementing bundle on
healthcare – decreased ventilator days
Impact of Implementing
and length of stay
Bundle on Health Care
 Implementing daily spontaneous awakening trials:²
Ventilator
days - ↓on2.4
days
5
 Early mobility
of patients
ventilators
- ↓↓3.5
 LOS inLOS
the ICU
1.4days
days
 Using
LOS innon-Benzodiazepines
the hospital ↓ 3.3 days vs. Benzodiazepines sedation³
6
- ↓ 1.9 days
 Delirium Ventilator
detection days
and prevention
 LOS ↓ LOS
3.6 days
- ↓ 1.62 days
Decreased VD and LOS
 Incidence of delirium ↓ 1.6%
2 Rose, Louise; Maunder, Robert; Hunter, Jon, et al. Sleep, cognitive, and psychological morbidity following sedation protocol
and daily sedative interruption vs. sedation protocol alone in critically ill, mechanically ventilated adults (SLEAP-SCP). CCM
.2012: 40(12) p 1–328
³Fraser, G.L., Devlin, J.W., Worby, C.P. et al. Benzodiazepine versus nonbenzodiazapine –based sedation for mechanically
ventilated , critically ill adults: a systematic review and meta-analysis of randomized trials. CCM 2013; 41(9), p 30-8
Projected Cost Savings of
Implementation of the ABCDEF Bundle
 Cost savings (from national averages)5,7-8
 SATs
 VD 2.4 x $1,522 (1 VD) = $3,652
 LOS 3.3 x $3,500 (1 ICU day) = $11,550
 Early Mobility
 LOS in hospital = $18,544.80 in 1 month
 Delirium
 Incremental cost of total episode of care = $8,19959
Project Logo and Catch Phrase:
“Collaborate to Extubate”
Study Design
 Convenience sample of nurses working in all areas at MGH that
have patients who are ventilated
 Survey design adapted from AACN Pearl: Implementing the ABCDE
Bundle at the Bedside and unit gap analysis to assess:
 Communication and collaboration
 Sedation awakening/spontaneous breathing trial/coordination and choice of
sedation
 Delirium
 Early exercise
 Family involvement
Data Collection Procedure
 IRB approval per MGH policy
 Met with nurse directors and CNSs of ICUs for approval
and permission to send survey to staff
 Survey sent via Qualtrics
 Emailed weekly survey reminders
 Used posters and offered candy in snowman-decorated
boxes to remind staff to take survey
Demographics
 N = 212 respondents
 How many years as a nurse?
 Mean = 14.4 + 11.34
 Highest level of nursing education
 AD: 9%, BSN: 79.7%, MSN: 9.9%, Doctorate: 0.9%
 CCRN certification
 17% (36 RNs)
Demographics
Which unit do you work on?
 Blake 12 ICU: 10.8%
 Burn ICU (Bigelow 13): 2.8%
 Cardiac ICU (Ellison 9): 14.6%
 Cardiac Surgical ICU (Blake 8): 5.7%
 Medical ICU (Blake 7): 15.6%
 Neuroscience ICU (Lunder 6): 18.4%
 PICU: 4.7%
 RACU (Bigleow 9): 8.5%
 Surgical ICU (Ellison 4): 17.5%
Survey Results
Communication and Collaboration10
Yes/
No/
Always Never
Every nurse on our unit embraces true
collaboration as an ongoing process and invests in
its development to ensure a sustained culture of
collaboration.
89.5%
10.5%
Every nurse contributes to the achievement of
common unit goals.
90.4%
9.6%
All staff nurses are informed and knowledgeable
about patient outcomes and performance
improvement data for our unit.
81.9%
18.1%
Survey Results
Sedation Awakening Trial/
Spontaneous Breathing Trial/
Coordination and Choice of Sedation
Our unit has a sedation and analgesia protocol in
place.
Yes/
No/
Always Never
72.2%
27.8%
91%
9%
Our nurses currently perform Spontaneous
Awakening Trials (SATs, aka “sedation vacations”)
daily on all patients receiving sedation.
72.3%
27.7%
We have a standardized protocol for performing
SATs.
70.1%
29.9%
The nurses routinely perform both a pain and
sedation assessment on patients, using a validated
tool.
Survey Results
Delirium Assessment and Management
Yes/
No/
Always Never
All patients are assessed daily for the presence of
delirium.
69.5%
30.5%
Our nurses use a validated tool to assess for the
presence of delirium (CAM-ICU, ICDSC, pCAMICU).
46.9%
53.1%
Our nurses have a standardized delirium
management protocol.
24.5%
75.5%
Delirium monitoring is included in our daily
rounds for patients.
38.8%
61.2%
Survey Results
Early Exercise and Progressive Mobility
Yes/
No/
Always Never
Our nurses have a protocol for early exercise and
progressive mobility for patients.
67.5%
32.5%
Immobile patients on our unit receive passive
range of motion regularly, if tolerated.
62.2%
37.8%
Our nurses have the necessary support equipment
to safely assist with patients’ increased mobility.
78.4%
21.6%
Respiratory therapists and physical therapists are
available to assist with implementing early
exercise and progressive mobility protocols.
83%
17%
61.7%
38.3%
Mobility is addressed during daily rounds.
Survey Results
Family Involvement
Our nurses provide a family-centered philosophy
of care that supports visitations.
Yes/
No/
Always Never
99%
1%
Families are encouraged to give their input and
ask questions.
97.1%
2.9%
Family support and participation in all aspects of
patient care are encouraged.
88.7%
11.3%
Our nurses recognize the importance of updating
families daily regarding their loved one’s
condition.
99.5%
0.5%
Hospital Fiscal Savings
VD and LOS
 Reduction in VD by 1.21% (50 days/quarter)
 Projected cost savings per quarter: $76,100
 50 VD x $1,522 (average cost/VD)7
 Projected annual savings = $305,600
 $76,400 x 4 quarters
 No reduction in LOS
Educational Intervention
 Live educational sessions on each unit, 1 on day shift and
1 during evening (with 2 repeated for a total of 20 live
sessions)
 Assessed current practice with each unit’s specific patient
population
 Celebrated practices that were
already in place and educated staff
on other parts of bundle
 HealthStream PowerPoint slides
 Education on best practices
Education - Best Practices
 CAM-ICU and P-CAM ICU delirium assessment tools
 SAT/SBT and mobility protocols
 Delirium prevention strategies – “Give PEACE a Chance”
Physiologic, Environmental, ADLs/Sleep, Communication,
Education/Evaluation 11
Strategies to Enhance Participation
Poster Distributed to All ICUs
Future Directions
 Met with Dr. Perrin Cobb (Director of the Massachusetts
General Hospital Critical Care Center and Vice Chair for
Critical Care in the Department of Anesthesia, Critical Care
and Pain Medicine) about CSI project. He recently
presented the ABCDE bundle in a critical care grand
rounds.
 MGH CSI Team has been invited to take part in hospital-wide
implementation.
 Widespread use of CAM-ICU delirium assessment
 Mobility protocols
 Continued re-assessment of impact on LOS and VD
Special Thanks
 AACN CSI Faculty: Dave Hanson, MSN, RN, CNS, NEA-BC
 Chief Nurse and Senior Vice President for Patient Care at
MGH: Jeanette Ives Erickson, RN, DNP, FAAN
 MGH Coaches: Colleen K. Snydeman, RN, PhDc, NE-BC and
Susan Stengrevics, RN, MSN, ACNS-BC, CCRN
 MGH Norman Knight Nursing Center for Clinical and
Professional Development: Kathryn Larivee, RN, MSN
 MGH Yvonne Munn Center for Nursing Research: Dorothy
Jones, EdD, FAAN; Mary Duffy, RN, PhD; Susan Lee, RN, PhD;
and Jane Flanagan, PhD, ANP-BC
References
1. Edwards EE, Despotopulos LD, Carroll DL. Changes in provider perceptions of family
presence during resuscitation. Clin Nurse Spec. 2013;27(5):239-244.
2. Rukstele CD, Gagnon MM. Making strides in preventing ICU-acquired weakness: involving
family in early progressive mobility. Crit Care Nurs Q. 2013;36(1):141-147.
3. Rose L, Maunder R, Hunter J, et al. Sleep, cognitive and psychological morbidity following
sedation protocol and daily sedative interruption vs sedation protocol alone in critically ill,
mechanically ventilated adults (SLEAP-SCP). Crit Care Med. 2012;40(12suppl 1):1-328.
4. Fraser GL, Devlin JW, Worby CP, et al. Benzodiazepine versus nonbenzodiazapine–based
sedation for mechanically ventilated, critically ill adults: a systematic review and metaanalysis of randomized trials. Crit Care Med. 2013;41(9suppl1):S30-S38.
5. Morris PE, Goad A, Thompson C, et al. Early intensive care unit mobility therapy in the
treatment of acute respiratory failure. Crit Care Med. 2008;36(8):2238-2243.
6. Allen KR, Fosnight SM, Wilford R, et al. Implementation of a system-wide quality
improvement project to prevent delirium in hospitalized patients. Jclin Outcomes Manage.
2011;18(6):253-258.
References
7. Dasta JF, McLaughlin TP, Mody SH, Piech CT. Daily cost of an intensive care unit day: the
contribution of mechanical ventilation. Crit Care Med. 2005;33(6):1266-1271.
8. King L. Developing a progressive mobility activity protocol. Orthop Nurs. 2012;31(5):253262.
9. Research Triangle Institute for Center for Medicare & Medicaid Services. Analysis report:
Estimating the incremental costs of hospital-acquired conditions (HACs). 2012.
http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/HospitalAcqCond/index.html. Accessed April 1, 2014. (Click Incremental
Updated Cost Report).
10. American Association of Critical-Care Nurses. AACN standards for establishing and
sustaining healthy work environments: a journey to excellence. 2005.
http://www.aacn.org/WD/HWE/Docs/HWEStandards.pdf. Accessed April 18, 2012.
11. Balas MC, Rice M, Chaperon C, Smith H, Disbot M, Fuchs B. Management of delirium in
critically ill older adults. Crit Care Nurse. 2012;32(4):15-26.