Summary of the 'Project interprofessional collaboration and implementation of the ABCDEF bundle'

Background

Our sections ‘Generell Intensiv 1 and 2’  has a clear goal of reducing the harmful effects of deep sedation. The ABCDEF bundle is a collection of evidence-based practices that aim to reduce the harmful effects of pain, agitation/sedation, delirium, immobilization and sleep disturbances in intensive care patients (Ely et al 2017). Improvement in patient outcomes has been shown to be achieved proportionally to how much of the ABCDEF bundle the patient receives (dose-response effect) (Pun et al 2019).

The significant associated improvements depend on healthcare personnel's compliance with the recommendations contained in the 'bundle'. And here, interdisciplinary collaboration and communication are central to achieving effective use of the ABCDEF bundle. At General Intensive 1 and 2, we recognized that we had challenges especially when it came to:

1) oversedation and extensive use of midazolam,

2) prescribed daily patient plan and measures for depth of sedation and

3) procedures directing for increasing and decreasing sedatives and analgesics administrated as continuous infusions.

The starting point has been analgosedation. Increased focus and daily evaluation of the level of analgesia and sedation necessitates a change in culture and attitude, and has required the effort of an interprofessional approach of those included in the treatment of the ICU patient. It has been a goal to include physiotherapists and pharmacists in the work. The current 'OUS level-1 procedure for intensive care patients - pain, restlessness/agitation and delirium, adults', is the basis for the implementation of the ABCDEF bundle, as well as 'The Society of Critical Care Medicine's (SCCM) ICU Liberation Tool Kit' (Barr et al 2020).

Implementation

The implementation work started with a Kick-off seminar in mid-September 2021 where the focus was the letters A and C of the ABCDEF bundle, respectively Assessment, prevention and management of pain and Choice of sedatives and analgesics.

Points B, D, E and F in the bundle have not been the subject of a separate measure in the current protocol. By focusing on points A and C, we would still be able to facilitate a good assessment, prevention and management of delirium, early mobilization / training and active involvement of the family.

In order to achieve an appropriate plan for the patient, the aim has been for the treatment team to focus more on discussing the patient's level of sedation at the bedside and before the daily round which usually takes place outside the patient’s room. Valid assessment tools are used daily and documented in MetaVision (MV) in line with OUH level 1 procedure.

The patient record systems MV and DIPS were used to collect patient data in a prospective course. Demographic data such as sex, age, weight and height, the reason for admission to intensive care (respiratory failure, circulatory failure, sepsis, CNS failure, GI failure, Hematology, other) and diagnosis, as well as the extent and duration of respiratory support treatment (invasive mechanical ventilation, non-invasive ventilation and high-flow oxygen) were recorded. Indicated desired level of depth of sedation (RASS) and actual assessment of the current level of sedation was mapped, in addition to the use and volume (number of mg/kg and number of boluses) of sedation and analgesia.

Results from the project 'Interprofessional collaboration and implementaion of the ABCDEF-bundle in ICU'

Results

The following measures have been taken:

1. September-November 2021 Local approval of the project based on PVO OUH (Case number: 21/18315).

Teaching for physicians, nurses, one pharmacist and physiotherapists. Focus on points A and C in the ABCDEF bundle, analgosedation, use of valid assessment tools and recommendations on the selection and administration of drugs (PP-presentations)

2. 16^th of November 2021 Kick-off seminar. Start up project
3. November 2021- January 2022 Survey of physicians' and nurses' compliance with protocol; 22 patient courses with days of hospitalization from 2 to more than 30 days. Documentation of pain, sedation including prescription of sedation level, delirium, mobilization and contact with relatives, as well as general consumption of analgesics and sedatives.
4. February - May 2022 Focus on bolus-based analgosedation. Mapping of the quantity of drug administered as a bolus versus continuous infusion. 68 patient histories registered for day 1 to 7.

The summary from ABCDEF bundle reports 1 and 2 showed that:

• RASS prescription was consistently higher than registered RASS level
• The sedation level still seems to be too deep (cf. mobility and evaluation of RASS level and CAM-ICU)
• We had an increasing focus on bolus-based analgosedation, but we believe there is a potential for putting this more into the system

• Fewer patients as expected were documented as mobilized (cf. MV data; slightly high proportion of score 0 on the ICU mobility scale). Equally, there were several patients who were well mobilized. Question: Is this documented correctly, and is there a potential for improvement?
• We should have a clearer attitude towards the use of dexmedetomidine, for example by reducing the combination of large doses of propofol + dex, and using dex alone in patients assessed with RASS-3 and higher

5. June-September 2022 As a measure to increase our focus on pain, agitation/sedation and delirium a team from our section including 3 ICU nurses and 3 intensivists participated in the SandMan study that aimed: To describe international practice in ICU, and practice variation in the use of drugs, and monitoring for Pain, Agitation and Delirium (PAD) before and during the COVID-19 pandemic in patients with confirmed or suspected SARS-CoV2 infection, and to quantify the adherence to the PAD clinical guidelines. We included 60 patients from Generell intensiv 1 in the study (www.esicm.org/sandman/).

Further on we discussed how to proceed with the project, and considered it important to look at what happened during the daily rounds, and what focus the physician- and nurse groups respectively had on sedation and analgesia. We were looking for how the visiting situation was used in relation to discussions around analgesia and sedation, whether this was thematised to a sufficient extent and whether there was agreement between doctor and nurse in the patient assessment. We prepared some questions which we discussed in the professional environment and started the ‘Project daily round’ in January 2023.

6. January – May 2023 Project daily round

A limited sample of 24 nurse/physician pairs were interviewed directly after daily rounds. There was a high degree of agreement in the answers from nurses and doctors. Some main findings:

• The patients' need for analgesia and sedation was discussed in 4/5 cases, but approximately 1/3 of the answers suggest that you should spend more time on this
• Great agreement on what the patient's sedation level should be, but paradoxically, RASS was prescribed far less often than the target, namely daily.
• Full agreement that there was established a good plan for the patient's next 24 hours
• Around half of the responses in both occupational groups believed that more bolus-based analgosedation is appropriate
• There is disagreement as to whether the patient is assessed bedside, together by a physician and a nurse.

Conclusion ‘Project daily round’:

• Bolus-based analgosedation seems to play a significantly greater role, but it appears that physicians and nurses are not seizing the opportunity to be active and use this approach. There is a discrepancy between what is perceived as possible and what is done. There is therefore reasonable to conclude that we have a great opportunity to test bolus-based analgosedation in our section.
• It is worrying that so many nurses experience that the patients have not been assessed together bedside. This bedside situation is perceived important for the nurse in receiving a kind of confirmation and support of the appropriateness her/his assessment of the patient's condition. We have reason to believe that this may reflect that our physicians are generally using too short time bedside discussing the patient current condition and realistic goals for the next 24 hours.

Referanser

Barr J, Ghaferi AA, Costa DK, Hedlin HK, Ding VY, Ross C, Pun BT, Watson SR, Asch SM. Organizational Characteristics Associated With ICU Liberation (ABCDEF) Bundle Implementation by Adult ICUs in Michigan. Crit Care Explor. 2020 19;2(8):e0169. doi: 10.1097/CCE.0000000000000169

Ely EW. The ABCDEF Bundle: Science and Philosophy of How ICU Liberation Serves Patients and Families. Crit Care Med. 2017 Feb;45(2):321-330. doi: 10.1097/CCM.0000000000002175

Pun BT, Balas MC, Barnes-Daly MA, Thompson JL, Aldrich JM, Barr J…. Ely EW. Caring for Critically Ill Patients with the ABCDEF Bundle: Results of the ICU Liberation Collaborative in Over 15,000 Adults. Crit Care Med. 2019 Jan;47(1):3-14. doi: 10.1097/CCM.0000000000003482

What’s next?

This autumn senior consultant Kristin Wisløff-Aase will conduct a pilotstudy aimed to decrease deep sedation by following a treatment protocol directing for an analgosedation approach focusing on bolus medication.  This will include a close interprofessional collaboration and continue our focus on pain, sedation and delirium in ICU.

Two applications for funding to the Norwegian Regional Health Authorities and related to the Intensive and Critical Care Research Group (ICCRG) may be seen as a ‘spin-off’ and extension of the ABCDEF-project both by focusing on monitoring and manage sedation and delirium in ICU and by including more than one profession in the project group:

The CAPTAIN –study where senior consultant Andreas Barratt-Due is PI representing the ICCRG. This study primary aim is to study ARDS phenotypic heterogeneity, clinically and biologically. By including both community acquired pneumonia (CAP)- and trauma-induced ARDS, we have two distinct groups, one infectious and one non-infectious, that will be mapped separately and will act as each other´s comparator. The Secondary aims are to provide a broad clinical mapping of CAP- and trauma-induced ARDS with a specific focus on the occurrence of delirium, level of sedation, lung mechanics, etiologies and outcome. There is an urgent need to acquire a deeper mapping and understanding of the connection between level of sedation in ICU patients with severe respiratory failure, mechanical ventilation strategy and subsequent delirium and cognitive function. Hilde Wøien (also representing the ICCRG) will be one of the collaborator with special focus on sedation and delirium.

 ‘Precision sedation in intensive care ’. Professor Theresa Olasveengen is Principal and Site Investigator, UUS. This study aim to investigate the feasibility and efficacy of precision sedation in the ICU, using a combination of neurophysiologic and respiratory targets. The primary objective of the study is to determine whether precision sedation can improve patient outcomes compared to traditional sedation protocols. Secondary objectives include assessing the safety and feasibility of precision sedation, identifying patient characteristics that may impact the efficacy of the approach, and evaluating the impact of precision sedation on healthcare utilization and cost. Other members of the Steering Committee are MD PhD Luis Romundstad (Site Investigator, RH), RN PhD Hilde Wøien, and MD Ivan Rimstad.

Forskningsgruppen har hatt utfordringer med å etablere et felles prosjekt. Vi er organisert på ulike geografiske områder, og vi representerer ulike profesjoner. Høsten 2019 inviterte vi derfor landets intensivavdelinger til et seminar som kunne initiere et felles nasjonalt prosjekt med fokus på klinisk forskning i intensivavdeling. Ulike sentralsykehus fikk i oppgave å belyse hva som foregår av klinisk forskning i norske intensivavdelinger?  Dessverre har pandemien stoppet dette utgangspunktet for et samarbeidsprosjekt. Vi håper å ta fatt på arbeidet på et senere tidspunkt.

Ved Generell intensiv 1 og 2 ved RH gjennomfører vi nå et større kvalitetssikringsprosjekt med mål om å redusere skadelige effekter av sedasjon og analgesi noe man søker å oppnå ved å implementere ABCDEF-bundle hos oss. Intensivseksjonen ved Ullevål er invitert til å implementere samme prosjekt.

Tverrfaglig samarbeid og kommunikasjon er sentralt for å oppnå effektiv bruk av ABCDEF-bundle. Ved Generell intensiv 1 og 2 erkjenner vi at vi har en utfordring spesielt når det gjelder 1) oversedering og utstrakt bruk av midazolam, 2) plan og mål for sedasjonsdybde og 3) opp- og nedtrapping av sedativa og analgetika. Dette innebærer en vesentlig endring av våre daglige rutiner knyttet til håndtering av smerte, agitasjon/sedasjon, delirium, immobilisering og søvnforstyrrelser Assessment, prevention, and management of pain; Vurdering, forebygging og håndtering av smerte Both spontaneous awakening trials and spontaneous breathing trials; Både spontan vekking- og puste forsøk Choice of sedation and analgesia; Valg av sedativa og analgetika Delirium assessment, prevention, and management; Vurdering, forebygging og håndtering av delirium Early mobility and exercise; Tidlig mobilisering og trening Family engagement and empowerment; Aktiv involvering av familie. 

Økt fokus og daglig evaluering av analgesi- og sedasjonsnivå skal utøves av behandlingsansvarlige i et tverrfaglig fellesskap der utgangspunktet er analgosedasjon,- først og fremst smertelindre og deretter titrere sedasjon etter individuelt behov. På sikt er planen å benytte implementeringsarbeidet til å etablere en god database for å utvikle en forskningsstudie med flere armer og ulike design der nettopp analgosedasjon og ABCDEF-bundle er sentral.

Analgosedasjonsprosjekt ved generell intensiv 1 og 2

Go to the tab under 'Projects' for more information.