Implementation of the ABCDEF Bundle in an Academic Medical Center

Impacting the Bundle—Standardized Nurse Early Report Facilitation

Communication among the members of the interdisciplinary team is essential in caring for critically ill patients. One of the ways that the members of the interdisciplinary team communicate is through daily patient rounds. Our ABCDEF bundle/ICU liberation team members attend and participate in daily patient rounds in our 3 MICUs on a regular basis. The ABCDEF bundle/ICU liberation team members wanted to improve communication during patient rounds for all elements of the bundle.

Nurse Early Report Facilitation was a standard that was implemented approximately 5 years prior to the start of the ICU Liberation Collaborative. Nurse early report facilitation requires that the bedside staff RN starts the daily patient rounds discussion on each of his/her patients. The report given by the bedside RN was designed to last 60 to 90 seconds and provide dynamic information on the patient’s condition. Requiring the bedside RN to start the patient rounding provides the following benefits: requires bedside RN presence, provides up-to-the-minute information, increases bedside RN engagement in the patient’s plan of care, and allows for questions and answers. Compliance from the bedside RNs with this process of beginning patient rounds was very high; however, the information that was shared when the bedside RN began rounds was variable. Some bedside RNs provided a lengthy report on the patient while others provided 1 or 2 words.

The ABCDEF bundle/ICU liberation team members thought that a way to hardwire the ABCDEF bundle elements would be to add structure to the nurse early report. By using the ABCDEF elements as a guide, the ABCDEF bundle/ICU liberation team members developed the Structured Nurse Early Report Facilitation in which the bedside RN provides the following information at the beginning of each patient discussion during rounds: name of patient, overnight events (travels, clinical changes, etc.), pain (pain score and PRN use), agitation (RASS and PRN use), delirium (results of CAM-ICU). When the bedside RN performs the nurse early report using the structured format, the team is primed to discuss the A, B, C, and D elements of the bundle.

To implement the Structured Nurse Early Report Facilitation in the MICUs, the critical care clinical nurse specialists provided in-person education at the monthly staff meetings. They also sent emails, developed education bulletin boards, made reminder cards that were placed on the in-room computers, and distributed “badge buddy” reminder cards that fit on the RNs’ hospital ID badges. We provided emails and in-person education to our physician and nurse practitioner teams so they were aware of the changes. Our physician and nurse practitioners were encouraged to ask for information about any elements missing from the Structured Nurse Early Report in the early days of the process change.

After a few months, the critical care clinical nurse specialists reported that the Structured Nurse Early Report Facilitation was occurring for more than 80% of MICU patients. Besides the increase in information related to pain, agitation, and delirium, the Structured Nurse Early Report Facilitation increased the interdisciplinary team’s use of the term “delirium.” Prior to the structured nurse early report, most of the interdisciplinary team members were not naming delirium as a diagnosis for our MICU patients and used terms such as ICU psychosis, confused, and disoriented to describe the mental status of patients with delirium. As a result of this lack of naming, there may have been a lack of recognition of delirium. Using the word “delirium” has increased our interdisciplinary team’s awareness of this diagnosis and has increased the treatment of delirium in patients who have the diagnosis.

In addition to improved assessment and diagnosis, the clinical pharmacist began leading the discussions around choice of sedation during daily rounds. Team members began to discuss the patient’s sedation level, sedation goals, and develop a plan for each patient. This discussion included input from all members of the interdisciplinary team and allowed for a comprehensive patient-specific plan to be formed during the daily patient rounds episode.

Impacting the Bundle—Focus on Mobility

There have been many articles published in the critical care literature on the topic of mobility in the ICU. The evidence shows that early mobilization and rehabilitation of patients in ICUs is safe and may improve physical function, and reduce the duration of delirium, mechanical ventilation, and ICU length of stay [29–31]. Our institution had developed a critical care mobility guideline in 2008 for staff RNs to follow in determining the level of mobility that the patient required during the shift. Over the years, the mobility guideline was used less and less. As other tasks and interventions became a priority, mobility became an intervention that was completed for very few patients.

Our ABCDEF bundle/ICU liberation team determined that increasing mobility of our MICU patients needed to be a plan of care priority. We organized an interdisciplinary team to discuss the issues and barriers to mobility for our MICU patients. The interdisciplinary mobility team had representatives from medicine, nursing, respiratory therapy, physical therapy, occupational therapy, and speech therapy. Initially, this team sent a survey to all disciplines who provided care for the patients in the MICU. Data from this survey was analyzed by the team to determine next steps.