Implementation of the ABCDEF Bundle in an Academic Medical Center
Despite the fact that there were responses from 6 unique disciplines, several common barriers emerged. The largest barrier to overcome was staffing/time for mobility. It was clear from the survey respondents that all health care team members were busy providing patient care. Any change in the mobility guideline or practice needed to make efficient use of the practitioner’s time. Other barriers included space/equipment, communication, patient schedules, knowledge, patient and staff safety, and unit culture. The interdisciplinary mobility team divided into smaller workgroups to tackle the issues and barriers.
Mobility Rounds
Mobility rounds were implemented to attempt to decrease the barriers of time, communication, and know-ledge. Mobility rounds were designed as a start to the shift discussion on the topic of mobility. Mobility rounds included a clinical nurse specialist, a physical therapist (PT), an occupational therapist (OT), and a pulmonary physician/ nurse practitioner. This team met at 7:30 each weekday morning and walked room-to-room through our MICUs. The mobility rounds team laid eyes on each patient, developed a mobility plan for the day, and communicated this plan with the staff RN assigned to the patient. Mobility rounds were completed on all 48 MICU patients in 30 minutes.
Having the mobility rounds team at each patient’s bedside was important in several ways. First, it allowed the team members to see each patient, which gave the patient an opportunity to be part of his/her mobility plan. Also, the staff RNs and respiratory therapists (RTs) were often in the patient’s room. This improved communication as the staff RNs and RTs discussed the mobility plan with the PT and OT. For patients who required many resources for a mobility session, the morning bedside meeting allowed RNs, RTs, PTs, OTs, and physicians to set a schedule for the day’s mobility session. Having a scheduled time for mobility increased staff and patient communication. Also, it allowed all of the team members to adjust their workloads to be present for a complex mobility session.
,Another benefit of mobility rounds was the opportunity for the PT and OT team members to provide education to their nursing and physician colleagues. Many nursing and physician providers do not understand the intricacies of physical and occupational therapy practice. This daily dialogue provided the PT/OT a forum to explain which patients would benefit from PT/OT services and which would not. It allowed the RNs and physicians to hear the type of therapy provided on past sessions. It allowed the PT/OT to discuss and evaluate the appropriateness of each patient consult. It allowed the RN and physician to communicate which patients they felt were highest priority for therapy for that day. Mobility rounds are ongoing. Data are being collected to determine the impact of mobility rounds on the intensity of mobility for our MICU patients.
Nurse-Driven Mobility Guideline
Another subgroup revised the outdated critical care mobility guideline and developed the new “Nurse-Driven Critical Care Mobility Guideline.” The guideline has been approved through all of the medical center quality committees and is in the final copyright and publication stages, with implementation training to begin in the fall. The updated guideline is in an easy-to-read flowchart format and provides the staff RN with a pathway to follow to determine if mobility is safe for the patient. After determining safety, the staff RN uses the guideline to determine and perform the patient’s correct mobility interventions for his/her shift. The guideline has built in consultation points with the provider team and the therapy experts.
Other Mobility Issues
A third subgroup from the interdisciplinary mobility team has been working on the equipment and space barriers. This subgroup is evaluating equipment such as bedside chairs, specialty beds, and assistive devices. Many of our MICU patient rooms have overhead lifts built into the ceilings. This equipment is available to all staff at all times. The equipment/space subgroup made sure that there were slings for use with the overhead lifts in all of the MICU equipment rooms. They provided staff education on proper use of the overhead lifts. They worked with the financial department and MICU nurse managers to purchase 2 bariatric chairs for patient use in the MICU.
A fourth subgroup has been working on the electronic documentation system. They are partnering with members of the information technology department to update the nursing and provider documentation regarding mobility. They have also worked on updating and elaborating on the electronic activity orders for our MICU patients. There have been many changes to various patient order sets to clarify mobility and activity restrictions. The admission order set for our MICU patients has an activity order that allows our staff RNs to fully utilize the new nurse-driven critical care mobility guideline.
Impacting the Bundle—Family Engagement and Empowerment
Family support is important for all hospitalized patients but is crucial for ICU patients. The medical center implemented an open visitation policy for all ICUs in 2015. Despite open visitation, the communication between patients, families, and interdisciplinary ICU teams was deficient. Families spoke to many different team members and had difficulty remembering all of the information that they received.
To increase family participation in the care of the MICU patient, we invited family members to participate in daily rounds. The families were invited to listen and encouraged to ask questions. During daily rounds, there is a time when all care providers stop talking and allow family members to inquire about the proposed plan of care for their family member. For family members who cannot attend daily rounds, our ICU teams arrange daily in-person or telephone meetings to discuss the patient’s plan of care. RNs provide a daily telefamily call to update the designated family member on the patient’s status, answer questions, and provide support.
In addition to the medical support for families, there is an art therapy program integrated into the ICU to assist families while they are in the medical center. This program is run by a certified art therapist who holds art therapy classes 2 afternoons a week. This provides family members with respite time during long hospital days. There are also nondenominational services offered multiple times during the week and a respite area is located in the lobby of the medical center.
In addition to these programs, the medical center added full-time social workers to be available 24 hours a day/ 7 days a week. The social worker can provide social support for our patients and families as well as help facilitate accommodations for those who travel a far distance. The social worker plays in integral part on the ICU team, often bridging the gap for families that can be overlooked by the medical team.
Conclusion
Care of the ICU patient is complex. Too often we work in our silos of responsibility with our list of tasks for the day. Participating in the ABCDEF bundle/ICU Liberation Collaborative required us to work together as a team. We were able to have candid conversations that improved our understanding of other team members’ perspectives, helping us to reflect on our behaviors and overcome barriers to improving patient care.
Even though the ICU Liberation Collaborative has ended, our work at the medical center continues. We are in the process of evaluating all of the interventions, processes, and guideline updates that our ABCEDF bundle/ICU liberation team worked on during our 18-month program. There have been many improvements such as increased accuracy of pain and delirium assessments, along with improved treatment of pain in the MICU patient. We have noticed increased communication with the patient and family and among all of the members of the interdisciplinary team. We have changed our language to accurately reflect the patient’s sedation level by using the correct RASS score and delirium status by using the term “delirium” when this condition exists. There is increased collaboration among team members in the area of mobility. More patients are out of bed on bedside chairs and more patients are walking in the halls. Over the next several months our ABCEDF bundle/ICU liberation team will continue to review and analyze the data that we collected in the collaborative. We will use that data and the clinical changes we see on a daily basis to continue to improve the care for our MICU patients.
Corresponding author: Michele L. Weber, DNP, RN, CCRN, CCNS, AOCNS, OCN, ANP-BC, The Ohio State University Wexner Medical Center, 410 West 10th Ave., Columbus, OH 43210, Michele.weber@osumc.edu.
