Virginia Research Day 2021

THE EFFECTS OF IMPLEMENTING THE ABCDEF PROTOCOL IN AN ICU WITHIN A LEVEL III TRAUMA CENTER

Richard Miller D.O., William Cox D.O., Brady DeHart Ph.D.

Background

Results

Duration of Mechanical Ventilation

0 20 40 60 80 100

The ABCDEF protocol, which stands for Assess, prevent and manage pain, Both spontaneous awakening trials and spontaneous breathing trials, Choice of analgesia and sedation, Delirium: assess, prevent and manage, Early mobility and exercise, and Family engagement and empowerment, also known as the ICU Liberation Bundle, is an evidence-based model that combines the individual components involved in managing a patient on mechanical ventilation, into one interdisciplinary protocol. The Society of Critical Care Medicine provides resources for facilities to implement the protocol within their own Intensive Care Unit (ICU). It is well established that the longer a patient remains on mechanical ventilation, the more complications arise 1 . Recent studies have demonstrated significant improvement in ICU outcomes, when utilizing the protocol in tertiary care centers, including survival, ICU readmission, next-day mechanical ventilation, delirium and restraint use 2,3. However, no studies have specifically examined the protocol’s impact on mortality and duration of mechanical ventilation in a small, community hospital.

Duration of Mechanical Ventilation Year

χ 2 =11.805 · df=1 · φ=0.151 · p<0.001

<24 hours >24 hours

Time 2014 2015 2016 2017 2018 2019 Total <24 hrs 44 34 30 36 36 46 226

* Red Line indicates time of intervention

>24 hrs

83

76

56

39

40

26 320

Total

127 110 86

75

76

72 546

2014 2015 2016 2017 2018 2019

χ 2 =26.357 · df=5 · Cramer’s V=0.220 · p<.0.001

Mortality

Mortality Year

0 20 40 60 80 100

χ 2 =8.708 · df=1 · φ=0.130 · p<0.01

Expired Other

Objective

Time 2014 2015 2016 2017 2018 2019 Total

To determine if mortality and duration of mechanical ventilation were impacted by implementation of the ABCDEF protocol, in a 10 bed ICU within a Level III Trauma Center.

Expired

34 45 20 21

8

18 146

Other

93 65 66 54 68 54 400

* Red Line indicates time of intervention

Total

127 110 86 75 76 72 546

Methods

χ 2 =22.177 · df=5 · Cramer’s V=0.202 · p<0.001

2014 2015 2016 2017 2018 2019

References 1.Hortal J, Giannella M, Pérez MJ, Barrio JM, Desco M, Bouza E, Muñoz P . Incidence and risk factors for ventilator-associated pneumonia after major heart surgery. Intensive Care Med. 2009;35(9):1518. 2.Barnes-Daly MA, Phillips G, Ely EW. Improving Hospital survival and reducing brain dysfunction at seven California community hospitals: implementing pad guidelines via the ABCDEF bundle in 6,064 patients. Crit Care Med 2017;45:171 – 8. 10.1097/CCM.0000000000002149 3.Pun BT, Balas MC, Barnes-Daly MA, Thompson JL, Aldrich JM, Barr J, et al. Caring for critically ill patients with the ABCDEF bundle: results of the ICU liberation collaborative in over 15,000 adults. Crit Care Med. 2019;47:3 – 14. doi: 10.1097/CCM.0000000000003482 LewisGale Hospital Montgomery had 32.9% of patients receive mechanical ventilation for less than 24 hours pre-implementation of the intervention, which increased to 47.9% post-intervention. Additionally, 33.3% of patients on mechanical ventilation expired pre-intervention, which was reduced to 21.7% post-intervention. Overall, the odds of mortality decreased by 19% after implementation of the protocol. Statistical significance values listed on the tables above utilize data from each individual year, whereas those listed on graphs were derived from grouping data as either pre or post implementation.

Population

Intervention

Outcomes

Discussion

The ICU Liberation Bundle, or ABCDEF Protocol, is a non-invasive intervention that has been shown to only improve outcomes in the critical care setting. This study does have significant limitations, including the fact that data was analyzed on a macro-scale without accounting for the variety of variables impacting outcomes in critically ill patients. However, implementation of the protocol poses no risks to the patient, improves communication between members the patient care team, and has now been shown to be beneficial in almost every type of healthcare facility that manages ICU patients. Therefore, a strong argument should be made to universally implement the ABCDEF Protocol as the standard of care for mechanically ventilated patients. Conclusion The ABCDEF protocol effectively decreased mortality and duration of mechanical ventilation for mechanically ventilated patients at LewisGale Hospital Montgomery.

546 patients who required mechanical ventilation at LewisGale Hospital Montgomery, from 2014 to 2019

Implementation of the ABCDEF protocol

1) # of patients on vent greater than 24hrs vs less than 24hrs 2) # of patients who expired

• Protocol implemented in 2016 • Duration of Mechanical Ventilation determined by ICD 10 Codes: • 5A1935Z for <24hours • 5A1945Z and 5A1955Z for >24 hours • Mortality was determined by the discharge disposition description listed as “expired” within the database query

This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.

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