Michele C Balas PhD RN CCRNK FCCM FAAN Associate Dean of Research Dorothy Hodges Olsen Distinguished Professor of Nursing University of Nebraska Medical Center College of Nursing Disclosures ID: 1041706
Download Presentation The PPT/PDF document "Developing an Interprofessional Program ..." is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
1. Developing an Interprofessional Program of Research Focused on Reducing the Burden of ICU DeliriumMichele C. Balas PhD, RN, CCRN-K, FCCM, FAAN Associate Dean of Research Dorothy Hodges Olsen Distinguished Professor of Nursing University of Nebraska Medical Center College of Nursing
2. DisclosuresCurrent research support: NIH/NHLBI (R01-PI); NIH/NICHD (R01-Co-I)Past research support: Select Medical; Alzheimer's Association, RWJF INQRI, American Association of Critical Care NursesHonoraria for CME activities: H3C, SCCM
3. ObjectivesDescribe the known harms of ICU-acquired pain, deep-sedation, delirium, & immobilityDiscuss the safety, effectiveness, & barriers/facilitators to ABCDEF bundle adoptionExplore future opportunities in dissemination & implementation science in critical care
4.
5. Early Research
6. Support- BAGNC Pre-Doc- $100KPurpose- Examine the frequency & course of delirium in older adults admitted to a SICUDesign & MethodsProspective, observational cohort study (N=114)Older adults admitted to a SICU & their surrogatesChart reviews & surrogate interviews within 24 hours of SICU admissionScreened for delirium daily throughout their hospitalization
7. Results18.4% had evidence of dementia on SICU admission Few (2.6%) admitted to hospital with evidence of preexisting delirium28.3% developed delirium in SICU & 22.7% during post‐SICU period45.6% delirious sometime during their hospital stay ConclusionsOlder adults admitted to SICUs are at high risk for developing delirium. Further research needed to elucidate the risk factors for, & outcomes of, delirium in this uniquely vulnerable population
8. Support- BAGNC Post-Doc- $120KPurpose- Describe the association between the presence of delirium & complications in older SICU patients & explore the association between SICU delirium & functional ability & discharge placementMethodsSecondary analysis of prospective, observational, cohort study114 consecutive patients ≥ 65 years old admitted to a SCCSDaily, in-person delirium & sedation/agitation screening during hospitalization
9. ResultsNearly I/3 of older adults (31.6%) admitted to a SICU had a complication during ICU stayCompared to non-delirious patients, patients with delirium were more likely to:Be discharged to a place other than homeExperience greater functional declineMore likely to experience a complication
10. Support- UNMC CON Dean’s Research Grant- 5KPurpose- Determine the number of older adults who experience a change in their functional ability & residence after an ICU stay & explore risk factors for functional decline & new institutionalization MethodsProspective observational study (N=43)
11. ResultsHigh rates of unrecognized preexisting cognitive impairment, delirium, complications, functional decline, & new institutionalization Variables significantly associated with functional decline or new institutionalization included opioid administration, ICU complications, comorbidities, depression, & severity of illnessConclusionsA number of important & potentially modifiable factors influence an older adult's ability to recover after a critical illness
12. What did we know?Millions of survivors of critical illness worldwide experience profound & often persistent physical, mental, & cognitive health impairmentsThese impairments were commonly acquired in the ICU & often initiated and/or exacerbated by mechanical ventilation, symptom management, & immobility decisionsProlonged mechanical ventilation (MV)Post-traumatic stress disorderDepressionFunctional declineNew institutionalizationSevere neurocognitive dysfunction
13. In 2005, the RWJF launched a program to generate, disseminate, & translate research that is designed to help the public understand how nurses contribute to & improve patient care qualityInterdisciplinary Nursing Quality Research Initiative program (INQRI) supported 48 interdisciplinary teams of researchers who conducted rigorous studies linking nursing to patient care processes & outcomesINQRI’s final RFA solicited projects that would focus specifically on knowledge translation, specifically on either dissemination or implementation science
14. Implementation & Research Leaders
15. Tami Braley Support- RWJF INQRI- $300KPurpose- To evaluate the effectiveness & safety of implementing the ABCDE bundle into everyday ICU practice
16. Bundles in healthcareOrigin: 2001 The Institute for Healthcare Improvement (IHI) Definition: A small, straightforward set of evidenced based practices that when performed collectively & reliably, have been proven to improve patient outcomesGreat Success:Severe sepsisVentilatory associated pneumoniasCentral line infections16http://www.ihi.org/Topics/Bundles/Pages/default.aspx
17.
18. Why is ABCDEF bundle unique?18
19. Design & Methods18-month, prospective, cohort, before-after study conducted 2010-20125 adult ICUs, 1step-down unit, & 1 special care unit UNMCPatients— 296 (146 pre- & 150 post-bundle implementation), age ≥ 19 years, managed by CCSWInterventions—ABCDE bundle
20. Results: Process
21. Results: Clinical OutcomesPatients in the post-implementation period spent 3 more days breathing without mechanical assistance than did those in the pre-implementation period (median [IQR], 24 [7 to 26] vs. 21 [0 to 25]; p = 0.04)After adjusting for age, sex, severity of illness, comorbidity, & MV status, patients managed with the bundle experienced a near halving of the odds of delirium (OR, 0.55; 95% CI, 0.33–0.93; p = 0.03) & increased odds of mobilizing out of bed at least once during an ICU stay (OR, 2.11;95% CI, 1.29–3.45; p = 0.003)No significant differences noted in self-extubation or reintubation rates
22. Multi-center, single hospital system22
23. Setting: 7 community hospitals Sutter Heath SystemIncluded Team TrainingPatients: 6,064 24% ventilatedMixed general medical and surgical patients Barnes-Daly et al. Crit Care Med 2017;45(2):171-178.ABCDEF multi-center implementation study
24. ResultsEvery 10% increase in proportion of days of total bundle compliance 7% higher odds of hospital survival 2% increase of Delirium/coma free days(normal)Similar “dose response” results with partial bundle compliance Barnes-Daly et al. Crit Care Med 2017;45(2):171-178.
25. SCCM PADIS GuidelinesA robust & growing body of research, outlined in the PADIS guidelines, demonstrated clinical outcomes improve when integrated, interprofessional approaches to MV liberation, symptom management, & immobility are applied early in the course of critical illness
26. ABCDEF Bundle26ADECFBAssess, prevent, & manage painBoth SAT & SBTChoice of analgesia & sedationDelirium: assess, prevent & manageEarly mobility & exerciseFamily engagement & empowerment
27. 27Multi-center nationwide
28. > 6 pain assessments per day using a valid & reliable instrument Numeric Rating Scale (NRS) Critical Care Pain Observation Tool (CPOT)Behavioral Pain Scale (BPS)Analagosedation approachAPayen JF et al., CCM 2001;29: 2258-2263Gelinas C et al., AJCC 2006; 15(4):420-427
29. Both daily Spontaneous Awakening Trial (SAT) & Spontaneous Breathing Trial (SBT) EligibilityCoordinationSafety screen/success criteriaB
30. > 6 level of arousal assessments per day using a valid & reliable instrument Richmond Agitation Sedation Scale (RASS)Sedation Agitation Scale (SAS)Light levelTargetC Sessler N. et al. Am J Respir Crit Care Med. 2002;166:1338-1344. Riker RR. et al. Crit Care Med. 1999;27(7):1325-1329.
31. > 2 delirium assessments per day using a valid & reliable instrument Confusion Assessment Method ICU (CAM-ICU)Intensive Care Delirium Screening Checklist (ICDSC)Nonpharmacologic interventionsDEly EW. et al. 2001. JAMA. 286(21):2703-2710.Ely EW. et al. 2001. Crit Care Med. 29(7):1370-1379.Bergeon N. et. al. 2001. Inten Care Med. 27(859-864.
32. Mobility activities higher than active range of motion per dayDangling at edge of bedStanding at side of bedWalking to bedside chairMarching in placeWalking in room or hallE
33. Family member/significant other educated on ABCDEF bundle AND/ORParticipated in rounds; conference; plan of care; or ABCDEF bundle related careF
34. ICU Liberation CollaborativeSetting: 68 ICUs DiversityRegional (across the US)Type of ICUSize of HospitalCommunity, Academic and VAPatients: 15,226Diversity54% on VentAdmission Dx: sepsis, respiratory, neuro, cardiacPun, et al. Crit Care Med. 2019; 47:3-14
35. DefinitionsComplete performance-Received Every Eligible bundle element on any given dayProportional performance- Percentage of eligible bundle elements performed on any given dayDifference from compliance
36. ICU Liberation OutcomesOutcomesComplete Bundle Performance*P Value ICU discharge1.17 (1.05–1.30)< 0.004 Hospital discharge1.19 (1.01–1.40)< 0.033 Death0.32 (0.17–0.62)< 0.00136*Adjusted HR (95% CI)Pun, et al. Crit Care Med. 2019; 47:3-14
37. ICU Liberation OutcomesOutcomesComplete Bundle Performance*P Value Mechanical ventilation0.28 (0.22–0.36)< 0.0001 Coma0.35 (0.22–0.56)< 0.0001 Delirium0.60 (0.49–0.72)< 0.0001 Significant pain1.03 (0.88–1.21)0.7000 Physical restraints0.37 (0.30–0.46)< 0.000137*Adjusted OR (95% CI)Pun, et al. Crit Care Med. 2019; 47:3-14
38. ICU Liberation OutcomesOutcomesComplete Bundle Performance*P Value ICU readmission0.54 (037–0.79)< 0.001 Discharge destination0.64 (0.51–0.80)< 0.00138*Adjusted OR (95% CI)Pun, et al. Crit Care Med. 2019; 47:3-14
39. 39Results: Patient-Related OutcomesPun, et al. Crit Care Med. 2019; 47:3-14 Dose
40. 40Results: Symptom-Related OutcomesPun, et al. Crit Care Med. 2019; 47:3-14 Dose
41. 41Results: Symptom-Related OutcomesPun, et al. Crit Care Med. 2019; 47:3-14 Dose
42. 42Results: Symptom-Related OutcomesPun, et al. Crit Care Med. 2019; 47:3-14 Dose
43. 43Results: System-Related OutcomesPun, et al. Crit Care Med. 2019; 47:3-14 Dose
44. Do quality improvement collaboratives help increase ABCDEF Bundle adoption?
45. Monthly Percentage of Complete & Proportional ABCDEF Bundle Performance
46. Monthly Percentage of Individual Bundle Element Performance
47. Variation among Collaborative ICUs in Unadjusted Frequency of ABCDEF Bundle Performance
48. Barriers to ABCDF bundle adoption
49. Strategies used to increase bundle adoption- Oh my…………………Access new fundingAssess for readiness and identify barriers and facilitatorsAudit and provide feedbackBuild a coalitionCapture and share local knowledgeCentralize technical assistanceChange physical structure and equipmentChange record systemsConduct cyclical small tests of changeConduct educational meetingsConduct educational outreach visitsConduct local consensus discussionsConduct local needs assessmentConduct ongoing trainingCreate a learning collaborativeCreate new clinical teamsDevelop a formal implementation blueprintDevelop academic partnershipsDevelop an implementation glossaryDevelop and implement tools for quality monitoringDevelop and organize quality monitoring systemsDevelop educational materialsDevelop resource sharing agreementsDistribute educational materialsFacilitate relay of clinical data to providersFacilitationIdentify and prepare championsIdentify early adoptersInform local opinion leadersIntervene with patients/consumers to enhance uptake and adherenceInvolve executive boardsInvolve patients/consumers and family membersMake training dynamicMandate changeModel and simulate changeObtain and use patients/consumers and family feedbackObtain formal commitmentsOrganize clinician implementation team meetingsPrepare patients/consumers to be active participantsPromote adaptabilityPromote network weavingProvide clinical supervisionProvide ongoing consultationPurposely reexamine the implementationRecruit, designate, and train for leadershipRemind cliniciansRevise professional rolesStage implementation scale upStart dissemination organizationTailor strategiesUse advisory boards and workgroupsUse an implementation advisorUse data warehousing techniquesUse train-the-trainer strategiesVisit other sitesWork with educational institutions
50. Helpful Articles50Critical Care Nurse. 2019;39[1]:46-60
51. Helpful Articles51(Critical Care Nurse. 2019;39[1]:36-45
52. ABCDEF Bundle Data Summary52ADECFBConsistent Results:Brain dysfunction (delirium, coma)Lengths of stay, Mechanical ventilation lengthMortalityDose response: The more of the elements you do….the bigger the associationsImplementation is NOT easy