Contextual Issues Influencing Implementation and Outcomes Associated With an Integrated Approach to Managing Pain, Agitation, and Delirium in Adult ICUs
Contextual Issues Influencing Implementation and Outcomes Associated With an Integrated Approach to Managing Pain, Agitation, and Delirium in Adult ICUs
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DOI：
10.1097/ccm.0b013e3182a2c2b1
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发表时间：
2013-09-01
影响因子：
8.8
通讯作者：
Ely, E. Wesley
中科院分区：
文献类型：
--
作者：
Carrothers, Kathleen M.;Barr, Juliana;Ely, E. Wesley
设计：本研究的数据来源包括文献回顾、有计划的现场访问(包括访谈和观察)、简短的在线背景因素调查和自我报告的过程和结果数据。研究对象：四个参与的SF湾区ICU的所有患者都有资格被纳入这项试点研究。背景：本研究发生在参加ICU临床影响兴趣小组的四个旧金山湾区ICU，由戈登和贝蒂·摩尔基金会资助，从2012年1月到2013年6月。发明：这是一项试验性评估研究，旨在确定促进/阻碍ABCDE捆绑包实施的因素，旨在降低ICU获得性精神错乱和肌肉无力的患病率。ABCDE束包括自发觉醒试验、自发呼吸试验、觉醒和呼吸试验的协调、镇静的选择、精神错乱的筛查和治疗以及早期进行性活动。测量：在干预期间的基线和每月收集与束元素依从性相关的过程数据。结果数据(平均ICU住院时间和平均机械通气天数)在干预期间的基线和季度收集。主要结果：与ICU结构特征有关的因素、整个组织的患者安全文化、ICU质量改进的文化、实施规划、培训/支持以及提示/文档被认为促进了ABCDE捆绑实施的成功率和成功率。过多的人员流动(包括项目和ICU领导层)、员工士气问题、不同学科之间缺乏尊重、知识缺陷以及过度使用登记处工作人员被认为阻碍了实施。结论：成功实施ABCDE捆绑包的要素可以显著改善ICU患者护理。这项研究的结果突出了ICU和医院的特定结构和文化因素，这些因素可以对ABCDE捆绑等复杂护理捆绑的实施产生积极和消极的影响。需要进一步的研究来评估这些背景因素对更广泛种类的ICU和医院的影响。
Objective: This pilot study was designed to identify which contextual factors facilitate/hinder the implementation of the awakening, breathing, coordination, delirium, and early mobility (ABCDE) bundle for guidance in future studies.Design: The sources of data for this study included document review, planned site visits (including interviews and observations), a brief online contextual factors survey, and self-reported process and outcome data.Patients: All patients in the four participating SF Bay Area ICUs were eligible to be included in this pilot study.Setting: This study took place in the four San Francisco Bay Area ICUs participating in the ICU Clinical Impact Interest Group, funded by the Gordon and Betty Moore Foundation from January 2012 through June 2013.Interventions: This was a pilot evaluation study to identify factors that facilitated/hindered the implementation of the ABCDE bundle, interventions designed to decrease the prevalence of ICU-acquired delirium and muscle weakness. The ABCDE bundle consists of spontaneous awakening trials, spontaneous breathing trials, coordination of awakening and breathing trials, choice of sedation, delirium screening and treatment, and early progressive mobility.Measurements: Process data related to bundle element compliance were collected at baseline and monthly during the intervention period. Outcome data (average ICU length of stay and average days on mechanical ventilation) were collected at baseline and quarterly during the intervention period. Hospital-specific results of the online contextual factors survey and information gathered through interviews and observations during site visits also contributed to the analysis.Main Results: Factors related to structural characteristics of the ICU, an organizational-wide patient safety culture, an ICU culture of quality improvement, implementation planning, training/support, and prompts/documentation are believed to have facilitated the rate and success of ABCDE bundle implementation. Excessive turnover (both in project and ICU leadership), staff morale issues, lack of respect among disciplines, knowledge deficits, and excessive use of registry staff are believed to have hindered implementation.Conclusions: Successful implementation of the elements of the ABCDE bundle can result in significant improvements in ICU patient care. The results of this study highlight specific structural and cultural elements of ICUs and hospitals that can positively and negatively influence the implementation of complex care bundles like the ABCDE bundle. Further research is needed to assess the influence of these contextual factors across a broader variety of ICUs and hospitals.