Effects of a National Quality Improvement Collaborative on ABCDEF Bundle Implementation

Abstract

Background: The ABCDEF bundle (Assess, prevent, and manage pain and Delirium; Both spontaneous awakening and breathing trials; Choice of analgesia/sedation; Early mobility; and Family engagement) improves intensive care unit outcomes, but adoption into practice is poor.

Objective: To assess the effect of quality improvement collaborative participation on ABCDEF bundle performance.

Methods: This interrupted time series analysis included 20 months of bundle performance data from 15 226 adults admitted to 68 US intensive care units. Segmented regression models were used to quantify complete and individual bundle element performance changes over time and compare performance patterns before (6 months) and after (14 months) collaborative initiation.

Results: Complete bundle performance rates were very low at baseline (<4%) but increased to 12% by the end. Complete bundle performance increased by 2 percentage points (SE, 0.9; P = .06) immediately after collaborative initiation. Each subsequent month was associated with an increase of 0.6 percentage points (SE, 0.2; P = .04). Performance rates increased significantly immediately after initiation for pain assessment (7.6% [SE, 2.0%], P = .002), sedation assessment (9.1% [SE, 3.7%], P = .02), and family engagement (7.8% [SE, 3%], P = .02) and then increased monthly at the same speed as the trend in the baseline period. Performance rates were lowest for spontaneous awakening/breathing trials and early mobility.

Conclusions: Quality improvement collaborative participation resulted in clinically meaningful, but small and variable, improvements in bundle performance. Opportunities remain to improve adoption of sedation, mechanical ventilation, and early mobility practices.

Figure 1

Monthly percentage of complete ABCDEF bundle performance in the baseline (months 1–6) and implementation (months 7–20) periods.^{a a} Please refer to the Methods section and Supplemental Table 2 of the online-only supplement for a full description of the ABCDEF bundle components, eligibility requirements, and performance definitions.

Figure 2

Monthly percentage of individual ABCDEF bundle element performance in the baseline (months 1–6) and implementation (months 7–20) periods. Bundle elements: A, assess, prevent, and manage pain; B, spontaneous awakening trials (SATs) and spontaneous breathing trials (SBTs); C, choice of analgesia and sedation; D, delirium assessment, prevention, and management; E, early mobility and exercise; and F, family engagement and empowerment.^{a a} Please refer to the Methods section and Supplemental Table 2 of the online-only supplement for a full description of the ABCDEF bundle components, eligibility requirements, and performance definitions.

Figure 3

Variation among intensive care units in unadjusted frequency of ABCDEF bundle performance during the last month of the collaborative.^a Abbreviations: SAT, spontaneous awakening trial; SBT, spontaneous breathing trial. ^a Each box plot shows mean (diamond), median (line in shaded box), IQR (shaded box), points within 1.5 times the IQR (error bars), and any outliers (open circles) for unit-level performance rates.