Is there a difference in length of stay for the adult patient between those who are monitored with the ABCDE bundle and those who are not monitored with the ABCDE bundle while in the ICU?
Jessica O'Shea
Northern Arizona University
Abstract
The ABCDE bundle is an evidence-based, multidisciplinary approach to optimizing patient outcomes in the adult intensive care (ICU). The ABCDE bundle incorporates awakening, breathing, coordination, delirium monitoring and management, and early mobility to minimize potentially life changing effects of prolonged hospitalization, including the development of delirium. It is hoped that by conducting this study on the implementation of the ABCDE bundle, it will be found that the average patient had improved outcomes such as decreased ICU and hospital length of stay, decreased duration of mechanical ventilation, decreased prevalence and duration of delirium, and decreased health care costs. (Balas, 2012 p 35-48)
Is there a difference in length of stay for the adult patient between those who are monitored with the ABCDE bundle and those who are not monitored with the ABCDE bundle while in the ICU?
Intensive Care Units are exactly that, intensive. The patient is mostly like dependent on mechanical ventilation and around the clock care. The patient is typically so critical nurses are only assigned one patient due to the amount of attention these patients need. Mechanically vented patients are unable express their wants and needs, so it is up to the registered nurse and physicians to anticipate what those wants and needs are. If researchers can incorporate some sort of standard of care for this type of monitoring and implement it into the daily clinical practice, nurses can save the patient from possibly developing adverse reaction associated with extended length of stay in the ICU. (Critical Care Nurse, 2012;32[2]:35,40-48)
Roberts (2014) defines the ABCDE bundle is an acronym for awake, breathing, coordination, delirium monitoring, and early mobility. It is an assessment tool to help reduce the time an ICU patient remains on a ventilator. A is for awakening trials for ventilated patients. B is spontaneous breathing trials. C is for coordinating efforts between the registered nurse and respiratory therapist to perform a spontaneous breathing trial when the patient is awakened by reducing or stopping the patient’s sedation. The combination of sedation and analgesics being used are reviewed, and changes or reductions in the doses are considered. D a standardized delirium assessment program, including treatment and prevention options. E Early mobilization and ambulation of critical care patients with a physical therapist. (P.451-457)
Hypothesis: Is there a difference in length of stay for the adult patient between those who are monitored with the ABCDE bundle and those who are not monitored with the ABCDE bundle while in the ICU?
The research design for this type of study is by Perspective, observational cohort, before/after study design and because most ICU are smaller patient populations researchers would use the Qualitative study which has a sample size of less than 10 (Nieswiadomy, 2012 p.114)
The ABCDE bundle Implementation would need to be set up in as an Experimental Research design. I feel it is important to compare results immediately. Is this patient responding appropriately, yes or no? Then we modify the approach. If we implement the bundle there is a cause-and-effect relationship.
There are three primary areas to help solve this issue. Awaken trial and safety screen help determine if the patient meets the right criteria to continue to ventilate on their own. If the patient passes the safety screen and awaken trial, then the patient moves on to the second primary area. Spontaneous awakening trial (SAT). The purpose of SAT is reducing the amount of sedatives (the cause) to see if they can manage not being so sedated so that they can listen to commands and understand directions and what people are trying to tell them (the effect). If they can pass the SAT then they work on the third primary area, spontaneous breathing trial (SBT). SBT is the final and most important step because nurses are reducing the amount of ventilation that someone might require. Schweickert (2009) states, the earlier that you are able perform the ABCDE bundle or the more times you try this you should see faster awakening times in your patient which is the goal. If they fail the SBT you go back to the sedatives and try reducing them until they pass the criteria for the safety screen, ideally every 24 hours. (P. 373)
All experimental studies include manipulation or control of the independent variable (cause) and measurement of the dependent variable (effect). Controls are difficult to apply when experimental research is conducted with human beings. (Nieswiadomy, 2012 p.114)
Experimenter Effect is one of the biggest issues with this study. Not all nurses want to participate in changing how they care for their patients. This study is only valid if every day this bundle it used. The experimenter Effect is a threat to the study, because results that occur when the researchers (the nurse) judges the characteristics or behavior of the patient and this may be influential to how they approach the bundle. The nurse could not want to participate in the study, considering the patients’ health history, ETOH abuse, drugs or socioeconomic status. If the nurses involved in the study are not interested in implementing the bundle on every patient in the ICU every day, then the study will fail to show cause and effect and objective information bases on pre-bundle and post-bundle care. (Nieswiadomy, 2013 p.117)
Variables
What could influence the study? Staff Education is essential to implementation of the bundle. Multiple educational sessions open to nursing, respiratory therapy, and rehabilitation staff using various instructional methods. A presentation from management that highlights the evidence to support the implementation of the ABCDE bundle should be presented on several different occasions. A second presentation should be arranged to nursing staff on the proper administration of the bundle. If the staff do not feel comfortable, supported or well educated on this implementation they will be hesitant to use the bundle. An online learning module could be created to help review the information. Staff education and support is the utmost importance for successful implementation of the bundle.
The three main variables are the independent variables which can be controlled by the ICU nurse to the ICU patient being mechanically ventilated. The dependent variables which we hope are affected by our changes to sedation, breathing trials, and mobility which can be observed or measured in the experiment. Observation or measure of the dependent variable will change as the independent variable is altered. If we implement the bundle we see less ICU psychosis, and the patient can be vent dependent less days. Another challenge in this implementation is the control variable also known as the constant variable. The reason is that if the control variables aren’t held constant, in this scenario the nursing staff and their level of care they provide to the adult patient in the ICU. The scientist will not know if the dependent variable caused the change in the dependent variable or if the change was sure to the control variable. No two nurses are alike or practice nursing the same. Every nurse plans their shift differently and provides care based on their comfort level and effective time management skills. Helping to mentor your peers and lead by example. The implantation study might fail based on the independent variable on that shift. That’s why the education and consistence when performing the bundle is crucial to accuracy (Nieswiadomy, 2013 p.36).
Methods, Data Collection, and Setting
Data are the pieces of information or facts that are collected in scientific investigations. Although the data collection step of research process may be very time consuming, it is sometimes considered the most exciting part of research. (Nieswiadomy, 2012 p.39)
Data collection is a systematic process and the choice of method is determined by the study. This study involves human subjects; all nurses have the responsibility to act as advocates when their patients are involved in research. This advocacy involves making sure that the ethical aspects of research are upheld. Nurses should help answer questions and explain the study to potential participants before the study begins. In the bundle study the nurse should involve the ICU family in engagement and empowerment, because most of the time the patient is unable to communicate wants and needs. They also should be available during the study to answer questions or provide support to study participants and families.
Some of the questions that should be asked and answered include: Why is this study being conducted? Who is conducting it? Who is going to be in the study? What kind of tests and treatments are involved? How long will the study last? Nurses should serve as valuable resources for information and by getting the education and support they need, hopefully they won’t feel uncomfortable answering questions and implementation of the bundle. Treatment is most effective when implemented by nursing, respiratory care, physical therapy and the doctor all work together as a team.
Pre-experimental design more specifically One-group Pretest-Posttest Design provides a comparison between a group of subjects before and after the experimental treatment. Design threats to internal validity would be history, maturation, testing, and instrumentation change. Because of the pretest and posttest, testing and instrumentation change now becomes threats to internal validity. (Nieswiadomy, 2012 p.123)
Case studies are in-depth examinations of people or groups of people. A case study could also examine an institution like a hospital. A case study can be considered quantitative or qualitative research, depending on the purpose of the study. Content analysis involves the researcher to observe for patterns and themes. I feel like this fit this type of study because the communication would be prompt and completed daily.
The data collection will be documented pre-bundle and post-bundle, to capture the patient data relating to each of the components of the ABCDE bundle. Documentation prompts would be built in to the electronic medical record by the nurse informatics. A retrospective chart review via EMR would be used to obtain pre-bundle and post-bundle data. The daily census of patients in the ICU would be used to identify which medical records to access. Patients could be assigned an observation number, free of identifying demographic information such as age, gender, or admitting diagnosis.
Physiological measures that involve data collection of physical data from subjects. These types of measures are generally more objective and more accurate than many of the other data-collection methods. It is much more difficult for subjects to provide biased data on physiological measures in their precision and accuracy. One of the greatest disadvantages is that special expertise like the ICU nurse may be necessary to use some of these devices. For example, the process of certain data collection instruments to measure a person’s blood pressure may, in fact, cause the blood pressure readings to go up. (Nieswiadomy, 2012 p.123)
Population Sample
The population sample is adult patients admitted to the ICU on mechanical ventilation. They share some of the same characteristic of interest to the researcher. While the reason as to why the patient ended up in the ICU might differ, the plan of care and implementing the Bundle is the same. This type of population sample is from an available group also called the accessible population. The conclusion of a research study is based on data obtained from the accessible population, and statistical inference should be made only to the group from which the sample was selected.
Convenience sampling is also referred to as accidental or incidental and involves choosing readily available people for a study. Generally, family members of patients in the ICU are eager to get their loved one out of the ICU, off sedation and following commands. This makes this sample population easy to study. Convenience sampling is often used because it saves time and money. (Nieswiadomy, 2012 p.155-157)
The time frame for the Convenience sampling in this study will be cross-sectional, because it examines subjects at this specific point in time. The length of time the patient would be observed is depending on how long their ICU stay is. (Nieswiadomy, 2012 p.155)
Data analysis
Both descriptive and inferential statistics have their benefits and shortcomings. Descriptive statistics are great for a small population. You can accurately produce numbers for the population without worrying about being off or making any errors, but you can’t make any conclusions that go beyond the population that you have. You have the accuracy you want by its limited to a very small population in comparison to inferential statistics. With inferential statistics, you don’t need the data of the entire population to make your conclusion. You can make an educated guess on what the parameters of the entire population are no matter how large it may be. Both forms are great when used together you can get accurate parameters of a small population, and then take those parameters further and get great approximations of what a much larger population statistic are, like implementing the bundle in every ICU in America.
The ABCDE bundle is evidence-based Balas (2012) Incorporated the best evidence related to delirium, immobility, sedation/analgesia, and ventilator management in the ICU and tailors the nonpharmacological interventions used prior to clinical trials into a bundle that can be adopted into everyday clinical practice. (35-48) Per Johnson (2014) critically ill patients managed with the ABCDE bundle spent three more days breathing without assistance, experienced less delirium, and were more likely to be mobilized during their ICU stay than patients treated with usual care. (p.451-457)
Schweickert (2009) conducted a systematic review of interventions of ICU delirium and found that using the ABCDE care bundle, is associated with improved clinical outcome. In multiple studies Balas (2012), Needham (2010), Schweickert (2009) and Fraser (2015) found the odds of acquiring ICU delirium were reduced by almost half with a 95% confidence interval by using the ABCDE bundle.
Balas (2012) concluded that for the ABCDE bundle to have its full impact, it is recommended that healthcare providers consider using the bundle every day, in every adult patient admitted to an ICU. The ABCDE bundle should be implemented at least once a day based on when the nurse and or physical therapist deems appropriate. Quality Assurance or Director of Nursing could help to organize a team in the ICU to implement the ABCDE bundle or it could be part of the standard of care that the nurses and physical therapy work on together during their shift.
Human Subject’s Protection
In 1978 The National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research was formed. The identified three basic principles related to research subjects:
1) Respect for persons-research subjects should have autonomy and self-determination,
2) Beneficence-research subjects should be protected from harm
3) Justice- research subjects should receive fair treatment
(Nieswiadomy, 2012 p.21)
Human participants will be protected by coordinated efforts by the nurse and hospital staff to insure awakening trials and spontaneous breathing trails are safe and effective mechanisms for accessing a patient’s readiness to wean from the mechanical ventilator. Excessive sedation can prohibit successful weaning from the mechanical ventilator. As part of a nurse-led trail the legal decision maker typical the patient’s family with give consent for the use of the bundle to be performed. Some studies had the doctor write orders for the bundle to be an “Opt Out” only. Which means that consent was obtained by the doctor ordering the bundle to be implemented in the standard plan of care. Respect for the patient’s autonomy the patients could be assigned an observation number, free of identifying demographic information such as age, gender, or admitting diagnosis.
Conclusion
The ABCDE bundle is a cost-effective method to enhance multiple patient outcomes in the ICU. Because of synergistic effects of the bundle components, organizations should adopt all the of the components of the bundle to optimize therapeutic outcomes. Proper multidisciplinary collaboration and comprehensive staff education using multiple education delivery methods are essential for sustained culture change. Direct care staff nurses are a crucial component of successfully implementation of EBP’s at the bedside, such as the ABCDE bundle. As coordinators of care, they are the leader of the multidisciplinary team and active participants in each of the bundle’s components to ensure safe and effective care is delivered. Open communication and cooperation among the multidisciplinary team can assist the nurse in minimizing potential barriers that may be faced during implantation process and beyond.
In conclusion, the implementation of the ABCDE bundle is an evidence-based, cost-effective approach to improving clinical outcomes in the adult ICU. A strong leader, Comprehensive educational procedures, and transparency in the implementation process are needed to facilitate adherence by direct staff care. When all elements of the bundle are implemented simultaneously, the incidence of duration of delirium decline, patient length of ICU stay and length of hospital stay decline, the amount of time a patient may spend sedated and on a mechanical ventilator decreased, and overall health care cost are reduced.