Perceptions of Workload Burden and Adherence to ABCDE Bundle Among Intensive Care Providers

Abstract

Background The ABCDE interprofessional bundle (Awakening and Breathing Coordination, Delirium monitoring and management, and Early mobility) is recommended practice in intensive care, but adoption is limited. Objective To examine the relationship between ICU provider attitudes regarding the ABCDE bundle and ABCDE bundle adherence. Methods A one-time survey of ICU providers (N=268) was conducted in ten ICUs across the country. ICU providers must have worked ≥4 shifts/month. We examined the following provider attitudes: workload burden, difficulty carrying out the bundle, perceived safety, confidence, and perceived strength of evidence. Logistic regression models were used to examine the relationship of unit level provider attitudes with patient level (N=101) ABCDE bundle adherence, adjusted for patient age, severity of illness, and comorbidity. Results For every unit increase in workload burden, there was a 53% decrease in adherence to the ABCDE bundle (OR=0.47, CI=0.28–0.79, p=0.004). Bundle difficulty (OR=0.29, CI=0.08–1.07), perceived safety (OR=0.51, CI=0.10–2.65), confidence (OR=0.37, CI=0.10–1.35), and perceived strength of evidence (OR=0.69, CI=0.14–3.35) were not associated with ABCDE bundle adherence. For every unit increase in perceived difficulty carrying out the bundle, there was a 59% reduction in adherence with early mobility (OR=0.41, CI=0.19–0.90, p=0.027). Additionally, ABCDE bundle adherence (i.e., ventilator bundle) was less than DE bundle adherence (i.e., ventilator-free bundle) (97% vs. 72%, z=5.47, p<0.001). Conclusions Reported workload burden influences ABCDE bundle adherence. High perceived difficulty carrying out the bundle impacts adherence with early mobility. Focusing interventions on workload burden and factors influencing bundle difficulty may facilitate ABCDE bundle adherence.

Staged Implementation of Awakening and Breathing, Coordination, Delirium Monitoring and Management, and Early Mobilization Bundle Improves Patient Outcomes and Reduces Hospital Costs*

“…While studies in clinical practice settings suggest that implementation of the full ABCDE bundle is associated with clinical benefits, its uptake has been limited and implementation often incomplete. (21)(22)(23)(24)(25)(26)(27)(28) Sequential implementation of bundle components may improve overall execution by allowing providers to: 1) maximize efficacy of implementation by focusing on individual components, 2) assess process improvement by performing step-wise evaluation of components, and 3) make practice adjustments before moving to the next component. In addition, studies suggest that the efficacy of early mobilization can be maximized if programs to reduce unnecessary sedation and delirium are already in place.…”

Prevention and Management of Delirium in the Intensive Care Unit

“…Some are related to the patient, including safety concerns in terms of hemodynamical instability or lack of cooperation. 169 The majority are related to the clinician implementing the bundle, in particular lack of knowledge about its benefits, reluctance to follow guidelines, preference for autonomy, perceived increased workload, 170 and lack of confidence in the bundle's efficacy. [169][170][171] Finally, there are barriers related to the structure of the ICU, including culture and organization, teamwork, physical environment, lack of resources, and inadequate management/leadership.…”

“…169 The majority are related to the clinician implementing the bundle, in particular lack of knowledge about its benefits, reluctance to follow guidelines, preference for autonomy, perceived increased workload, 170 and lack of confidence in the bundle's efficacy. [169][170][171] Finally, there are barriers related to the structure of the ICU, including culture and organization, teamwork, physical environment, lack of resources, and inadequate management/leadership. 169,171,172 Practical Considerations for the Treatment of Delirium At the individual level, for the clinician at the bedside, the management of delirium can be difficult.…”

The ABCDEF Bundle for the Respiratory Therapist

“…RTs also facilitate communication between physicians, nurses, physical therapists, and other members of the care team. Additionally, utiliz-ing a multi-layered process of care can have barriers to implementation, [98][99][100] so understanding the individual elements, the impact that the ABCDEF bundle has in the care of critically ill patients, and the unique culture and organization of ICUs puts RTs in an instrumental position to implement best practices and provide insight into the necessary requirements for building the bundle in their own institutions.…”