Common Challenges to Effective ABCDEF Bundle Implementation: The ICU Liberation Campaign Experience

Michele C Balas; Brenda T Pun; Chris Pasero; Heidi J Engel; Christiane Perme; Cheryl L Esbrook; Tamra Kelly; Ken D Hargett; Patricia J Posa; Juliana Barr; John W Devlin; Alexandra Morse; Mary Ann Barnes-Daly; Kathleen A Puntillo; J Matthew Aldrich; William D Schweickert; Lori Harmon; Diane G Byrum; Shannon S Carson; E Wesley Ely; Joanna L Stollings

doi:10.4037/ccn2019927

Common Challenges to Effective ABCDEF Bundle Implementation: The ICU Liberation Campaign Experience

Crit Care Nurse. 2019 Feb;39(1):46-60. doi: 10.4037/ccn2019927.

Authors

Michele C Balas¹, Brenda T Pun², Chris Pasero³, Heidi J Engel⁴, Christiane Perme⁵, Cheryl L Esbrook⁶, Tamra Kelly⁷, Ken D Hargett⁸, Patricia J Posa⁹, Juliana Barr¹⁰, John W Devlin¹¹, Alexandra Morse¹², Mary Ann Barnes-Daly¹³, Kathleen A Puntillo¹⁴, J Matthew Aldrich¹⁵, William D Schweickert¹⁶, Lori Harmon¹⁷, Diane G Byrum¹⁸, Shannon S Carson¹⁹, E Wesley Ely²⁰, Joanna L Stollings²¹

Affiliations

¹ Michele Balas is an associate professor, Center of Excellence in Critical and Complex Care, College of Nursing, and a nurse scientist, Wexner Medical Center, The Ohio State University, Columbus. balas.17@osu.edu.
² Michele Balas is an associate professor, Center of Excellence in Critical and Complex Care, College of Nursing, and a nurse scientist, Wexner Medical Center, The Ohio State University, Columbus.
³ Chris Pasero is a pain management clinical consultant, El Dorado Hills, California.
⁴ Heidi Engel is a physical therapist, Department of Rehabilitative Services, University of California, San Francisco.
⁵ Christiane Perme is a physical therapist, Houston Methodist Hospital, Houston, Texas.
⁶ Cheryl Esbrook is an occupational therapist, University of Chicago Medicine, Chicago, Illinois.
⁷ Tamra Kelly is a respiratory therapist, Sutter Health, Sacramento, California.
⁸ Ken Hargett is a respiratory therapist, Houston Methodist Hospital.
⁹ Patricia Posa is a population health clinical integration leader, Saint Joseph Mercy Health System, Ann Arbor, Michigan.
¹⁰ Juliana Barr is a staff intensivist and anesthesiologist, VA Palo Alto Health Care System, Palo Alto, California, and an associate professor, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California.
¹¹ John Devlin is a professor of pharmacy, Northeastern University, and a clinical scientist, Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, Massachusetts.
¹² Alexandra Morse is a clinical pharmacist, Sutter Health.
¹³ Mary Ann Barnes-Daly is a clinical performance improvement consultant, Sutter Health.
¹⁴ Kathleen Puntillo is a professor of nursing emeritus, Department of Physiological Nursing, School of Nursing, University of California, San Francisco.
¹⁵ J. Matthew Aldrich is medical director, critical care medicine, and an associate clinical professor, University of California, San Francisco Medical Center, San Francisco.
¹⁶ William Schweickert is an associate professor of clinical medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia.
¹⁷ Lori Harmon is director of quality, Society of Critical Care Medicine, Mount Prospect, Illinois.
¹⁸ Diane Byrum is a quality implementation consultant, Innovative Solutions for Healthcare Education, LLC, Charlotte, North Carolina.
¹⁹ Shannon Carson is a critical care pulmonologist, University of North Carolina School of Medicine, Chapel Hill.
²⁰ E. Wesley Ely is a professor of medicine, Vanderbilt University School of Medicine, and associate director, VA Tennessee Valley Geriatric Research Education Clinical Center, Nashville, Tennessee.
²¹ Joanna Stollings is a clinical pharmacist, Department of Pharmaceutical Services, Vanderbilt University Medical Center.

PMID: 30710036
DOI: 10.4037/ccn2019927

Abstract

Although growing evidence supports the safety and effectiveness of the ABCDEF bundle (A, assess, prevent, and manage pain; B, both spontaneous awakening and spontaneous breathing trials; C, choice of analgesic and sedation; D, delirium: assess, prevent, and manage; E, early mobility and exercise; and F, family engagement and empowerment), intensive care unit providers often struggle with how to reliably and consistently incorporate this interprofessional, evidence-based intervention into everyday clinical practice. Recently, the Society of Critical Care Medicine completed the ICU Liberation ABCDEF Bundle Improvement Collaborative, a 20-month, nationwide, multicenter quality improvement initiative that formalized dissemination and implementation strategies and tracked key performance metrics to overcome barriers to ABCDEF bundle adoption. The purpose of this article is to discuss some of the most challenging implementation issues that Collaborative teams experienced, and to provide some practical advice from leading experts on ways to overcome these barriers.

MeSH terms

Cooperative Behavior
Critical Care / standards*
Critical Illness / therapy*
Evidence-Based Practice / standards
Humans
Intensive Care Units / standards*
Patient Care Bundles / standards*
Quality Improvement*