Implementation Strategies Used to Facilitate ABCDEF Bundle Adoption: A Scoping Review
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Date
2020-05
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The Ohio State University
Abstract
Problem: Administration of the ABCDEF bundle (A - Assess, prevent, and manage pain; B - Both spontaneous awakening trials and spontaneous breathing trials; C - Choice of analgesia and sedation; D - Delirium: assess, prevent, and manage; E - Early mobility/exercise; F - Family engagement/empowerment) is associated with improvements in a number of important patient-centered outcomes. Despite its demonstrated safety and effectiveness, overall adoption of the ABCDEF bundle and its individual components into everyday clinical practice remains low.
Purpose: The purpose of the scoping review is to identify strategies used by prior studies and quality improvement (QI) efforts to facilitate ABCDEF bundle implementation and critically evaluate the implementation strategies that were used to facilitate adoption of this evidence-based, interprofessional intervention.
Methods: A scoping review of electronic databases (CINAHL, PubMed, Web of Science, Scopus, PsychInfo, Medline) was completed. Research studies, QI projects, systematic reviews, or metanalyses published from 2009-2020, in English, and available as full-text articles which described implementation of either the ABCDE bundle or ABCDEF bundle in the intensive care unit were eligible for inclusion. Studies that did not explicitly mention the ABCDE or ABCDEF bundle, were conducted solely with the pediatric population, or focused only on one element of the bundle (e.g., early mobility) were excluded. The Expert Recommendations for Implementing Change (ERIC) compilation provided 73 implementation strategies used to guide data extraction. Content analysis was performed and summary statistics were reported.
Results: Ten studies were eligible after screening 368 titles and abstracts and reviewing 23 full-text studies. Across studies, an average of 35 different strategies were used, with studies integrating a range of 8-54 strategies per study. The most frequently used implementation strategies included an implementation glossary, educational materials, bundle facilitation, providing clinical supervision, and recruiting/training for leadership. Seventeen ERIC strategies were not used and, importantly, no studies reported testing the effectiveness of any of the implementation strategies efforts that were used to increase bundle adoption.
Implications for practice: Future evaluation of implementation strategies used in ABCDEF bundle implementation is essential to effectively allocate efforts and resources. Future research should focus on t identifying, testing, and reporting the specific methods and resources needed for effective and sustained ABCDEF bundle implementation. Until effective implementation is understood, the excessively high morbidity, mortality, and cost associated with standard critical care delivery will continue and the public health benefit of the ABCDEF bundle will not be fully realized.
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Keywords
ABCDEF bundle, implementation, barriers, facilitators, intensive care unit, ICU