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

Update ICU Liberation: Executing the ABCDEF Bundle Daily April 4, 2019

Enacting the ABCDEF Bundle Society of Critical Care Medicine: Penn Medicine: • ICU Liberation 6 Hospitals • • 69 ICUs across USA 16 ICUs 2

Design Clinical Algorithm Real time feedback Tracking performance Text alerts to Patient RT and RNs hemodynamically stable + Patient meets criteria for sedation minimization and/or spontaneous breathing Updates the ICU Board 3

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Nursing Assessment Confusion Assessment Method (Delirium) Measure Delirium Assessment q 12 hours 100% 90% 80% 70% UCL 60% 50% LCL 40% 30% 20% 10% 0% 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 Richmond Agitation Sedation Score (RASS) Sedation/Agitation Assessment q 4 hours Measure 90% 80% 70% UCL 60% LCL 50% 40% 30% 20% 10% 0% 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 5

Goal Setting and Performance Feedback AWAKE BREATHING 6

ABC Alert – Smartphone Text Alerts SAT Alert SBT Alert 7 Anderson et al. AJRCCM 2018;197:A7786 (peer review)

Sedation Minimization Proportion of patients who received an alert and the RN Measure minimized a continuous sedative infusion 0.8 0.7 UCL 0.6 0.5 LCL 0.4 0.3 0.2 0.1 14% overall increase in sedation minimization practice 0 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 8

Mechanical Ventilation Median (days) Duration of Mechanical Ventilation Excluding H&V 2.5 2 1.92 2 1.79 1.7 1.7 1.63 1.52 1.48 1.45 1.4 1.5 1.3 days 1.07 1 0.5 ICU Board Go-Live I-LEAD introduced to UBCLs 0 2017 Q3 2017 Q4 2018 Q1 2018 Q2 2018 Q3 2018 Q4 Trachs Included Trachs Excluded 9

Duration of MV Measure 0.5 1.5 2.5 3.5 0 1 2 3 4 8/27/17 LCL UCL 9/3/17 9/10/17 9/17/17 9/24/17 Overall 0.4 day (10 hour) reduction in median duration of mechanical ventilation 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 Median Duration of Mechanical Ventilation 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 10 10

ICU LOS Unit Pre: Post: Reduction in hours Baseline (5/17-2/18) Current (3/18-1/19) Median ICU LOS Median ICU LOS Vented Patients Vented Patients #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 11 11

Delirium Duration Measure 0.5 1.5 2.5 3.5 4.5 0 1 2 3 4 8/27/17 LCL UCL 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 Median Duration of Delirium - All patients/All ICUs 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 12 12

“E” - Early Exercise  Standardized daily mobility goal setting  Performance Feedback  Facilitator role and communication strategy 13 13

Standardized practice Systems compliance with standardized mobility documentation 97% 89% 67% 6 Month Baseline Jan-19 Feb-19 14 14

Goal Setting and Performance Feedback ACTIVITY AWAKE BREATHING Baseline pre-admission mobility Yesterday’s peak level of activity Today’s peak level of activity PT/OT Consultation 15 15

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