Abcdef

Importance The ABCDEF bundle is a guideline-recommended framework for implementing evidence-based practices in the Intensive Care Unit (ICU), but it is underutilized across the world.Objective Describe the physical environment factors (i.e., availability, accessibility) of bundle-enhancing items in units implementing the bundle and the influence of physical environment on bundle adherence.Design, Setting, and Participants This multicenter, exploratory, cross-sectional study used data from two ICU-based randomized controlled trials (RCTs) (NCT01211522 and NCT01739933) that measured daily bundle adherence. The study included 10 medical and surgical ICUs in 6 academic medical centers in the continental United States. Adults with qualifying respiratory failure and/or septic shock (e.g., mechanical ventilation, vasopressor use) were included in the RCTs. Unit- and patient-level data collection occurred between 2011 and 2016. We conducted hierarchical logistic regression models using Frequentist and Bayesian frameworks.Exposure The ABCDE bundle (Awakening and Breathing trial Coordination, Delirium assessment/management, Early mobility) was recommended standard of care for RCT patients and adherence tracked daily.Measure(s) The primary outcome was adherence to the full bundle and the early mobility bundle component as identified from daily adherence documentation (n=751 patient observations). Unit-level measures included minimum and maximum distances to 25 bundle-enhancing items and the relationship to bundle adherence.Results In all cases, mechanical ventilation was associated with decreased bundle adherence. Some of the models suggested the following variables were also influential: age (older associated with decreased adherence), unit size (larger associated with decreased adherence), and a standard walker (presence associated with increased adherence).Conclusions and Relevance Both unit- and patient-level barriers influenced full bundle and early mobility implementation. There is potential benefit of physical proximity to essential items for ABCDEF bundle and early mobility adherence. Future studies with larger sample sizes should explore how equipment location and availability influences practice.Question Does the physical environment, specifically the availability and accessibility of ABCDEF bundle-enhancing items, influence bundle adherence?Findings In this cross-sectional study in 10 units evaluating ABCDEF bundle adherence across 751 patient observations, units with access to a standard walker were significantly more likely to provide bundled care. Across all models, patients who were on the ventilator or older were significantly less likely to received bundled care.Meaning Both unit- and patient-level factors influence ABCDEF bundle implementation and amenable targets for implementation strategy development.