Bundle Daily April 4, 2019 Enacting the ABCDEF Bundle Society of - - PowerPoint PPT Presentation

April 4, 2019

Update

ICU Liberation: Executing the ABCDEF Bundle Daily

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Enacting the ABCDEF Bundle

Society of Critical Care Medicine: ICU Liberation

• 69 ICUs across USA

Penn Medicine:

• 6 Hospitals
• 16 ICUs

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Design

Patient hemodynamically stable Patient meets criteria for sedation minimization and/or spontaneous breathing

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Clinical Algorithm

Text alerts to RT and RNs Updates the ICU Board

Real time feedback Tracking performance

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Nursing Assessment

Confusion Assessment Method (Delirium) Richmond Agitation Sedation Score (RASS)

UCL LCL

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 3/1/17 4/1/17 5/1/17 6/1/17 7/1/17 8/1/17 9/1/17 10/1/17 11/1/17 12/1/17 1/1/18 2/18/18 3/18/18 4/18/18 5/18/18 6/18/18 7/18/18 8/18/18 9/18/18 10/18/18 11/18/18 12/18/19 1/19/19 2/19/19

Delirium Assessment q 12 hours

Measure

UCL LCL

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 3/1/17 4/1/17 5/1/17 6/1/17 7/1/17 8/1/17 9/1/17 10/1/17 11/1/17 12/1/17 1/1/18 2/18/18 3/18/18 4/18/18 5/18/18 6/18/18 7/18/18 8/18/18 9/18/18 10/18/18 11/18/18 12/18/19 1/19/19 2/19/19

Sedation/Agitation Assessment q 4 hours

Measure

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Goal Setting and Performance Feedback

AWAKE BREATHING

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ABC Alert – Smartphone Text Alerts

SAT Alert SBT Alert

Anderson et al. AJRCCM 2018;197:A7786 (peer review)

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Sedation Minimization

UCL LCL

0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 1/1/18 2/1/18 3/1/18 4/1/18 5/1/18 6/1/18 7/1/18 8/1/18 9/1/18 10/1/18 11/1/18 12/1/18 1/1/19 2/1/19

Proportion of patients who received an alert and the RN minimized a continuous sedative infusion

Measure

14% overall increase in sedation minimization practice

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Mechanical Ventilation

2 1.79 1.92 1.45 1.7 1.7 1.63 1.4 1.52 1.07 1.3 1.48 0.5 1 1.5 2 2.5 2017 Q3 2017 Q4 2018 Q1 2018 Q2 2018 Q3 2018 Q4

days

Median (days) Duration of Mechanical Ventilation Excluding H&V

Trachs Included Trachs Excluded

I-LEAD introduced to UBCLs ICU Board Go-Live

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Duration of MV

UCL LCL

0.5 1 1.5 2 2.5 3 3.5 4 8/27/17 9/3/17 9/10/17 9/17/17 9/24/17 10/1/17 10/8/17 10/15/17 10/22/17 10/29/17 11/5/17 11/12/17 11/19/17 11/26/17 12/3/17 12/10/17 12/17/17 12/24/17 12/31/17 1/7/18 1/14/18 1/21/18 1/28/18 2/4/18 2/11/18 2/18/18 2/25/18 3/4/18 3/11/18 3/18/18 3/25/18 4/1/18 4/8/18 4/15/18 4/22/18 4/29/18 5/6/18 5/13/18 5/20/18 5/27/18 6/3/18 6/10/18 6/17/18 6/24/18 7/1/18 7/8/18 7/15/18 7/22/18 7/29/18 8/5/18 8/12/18 8/19/18 8/26/18 9/2/18 9/9/18 9/16/18 9/23/18 9/30/18 10/7/18 10/14/18 10/21/18 10/28/18 11/4/18 11/11/18 11/18/18 11/25/18 12/2/18 12/9/18 12/16/18 12/23/18 12/30/18 1/6/19 1/13/19 1/10/19 1/27/19

Median Duration of Mechanical Ventilation

Measure

Overall 0.4 day (10 hour) reduction in median duration of mechanical ventilation

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ICU LOS

Unit Pre: Baseline (5/17-2/18) Median ICU LOS Vented Patients Post: Current (3/18-1/19) Median ICU LOS Vented Patients Reduction in hours

#1 4.8 4.46

• 8

#2 4.8 4.58

• 5

#3 4.7 3.02

• 40

#4 2.3 2.06

• 6

#5 4.8 4.13

• 16

#6 3.6 3.67 +1.7 #7 3.7 3.13

• 14

#8 3.7 2.42

• 30

#9 3.5 3.17

• 8

#10 3.9 2.75

• 28

#11 2.0 2.27 +6 #12 2.7 3.67 +24 #13 3.8 4.96 +27 #14 3.9 3.57

• 8

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Delirium Duration

UCL LCL

0.5 1 1.5 2 2.5 3 3.5 4 4.5 8/27/17 9/3/17 9/10/17 9/17/17 9/24/17 10/1/17 10/8/17 10/15/17 10/22/17 10/29/17 11/5/17 11/12/17 11/19/17 11/26/17 12/3/17 12/10/17 12/17/17 12/24/17 12/31/17 1/7/18 1/14/18 1/21/18 1/28/18 2/4/18 2/11/18 2/18/18 2/25/18 3/4/18 3/11/18 3/18/18 3/25/18 4/1/18 4/8/18 4/15/18 4/22/18 4/29/18 5/6/18 5/13/18 5/20/18 5/27/18 6/3/18 6/10/18 6/17/18 6/24/18 7/1/18 7/8/18 7/15/18 7/22/18 7/29/18 8/5/18 8/12/18 8/19/18 8/26/18 9/3/18 9/16/18 9/23/18 9/30/18 10/7/18 10/14/18 10/21/18 10/28/18 11/4/18 11/18/18 11/25/18 12/4/18 12/9/18 12/16/18 12/23/18 12/30/18 1/6/18 1/3/19 1/20/19 1/27/19 2/3/19 2/10/19

Median Duration of Delirium - All patients/All ICUs

Measure

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“E”- Early Exercise

 Standardized daily mobility goal setting  Performance Feedback  Facilitator role and communication strategy

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Standardized practice

67% 89% 97%

6 Month Baseline Jan-19 Feb-19

Systems compliance with standardized mobility documentation

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Goal Setting and Performance Feedback

AWAKE BREATHING ACTIVITY

Baseline pre-admission mobility Yesterday’s peak level of activity Today’s peak level of activity PT/OT Consultation

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