title: Implementing the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle into everyday care: opportunities, challenges, and lessons learned for implementing the ICU Pain, Agitation, and Delirium Guidelines.
abstract: OBJECTIVE
  The awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle is an evidence-based interprofessional multicomponent strategy for minimizing sedative exposure, reducing duration of mechanical ventilation, and managing ICU-acquired delirium and weakness. The purpose of this study was to identify facilitators and barriers to awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle adoption and to evaluate the extent to which bundle implementation was effective, sustainable, and conducive to dissemination.
  
  
  METHODS
  Prospective, before-after, mixed-methods study.
  
  
  METHODS
  Five adult ICUs, one step-down unit, and a special care unit located in a 624-bed academic medical center
  
  
  METHODS
  : Interprofessional ICU team members at participating institution.
  
  
  METHODS
  In collaboration with the participating institution, we developed, implemented, and refined an awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle policy. Over the course of an 18-month period, all ICU team members were offered the opportunity to participate in numerous multimodal educational efforts. Three focus group sessions, three online surveys, and one educational evaluation were administered in an attempt to identify facilitators and barriers to bundle adoption.
  
  
  RESULTS
  Factors believed to facilitate bundle implementation included: 1) the performance of daily, interdisciplinary, rounds; 2) engagement of key implementation leaders; 3) sustained and diverse educational efforts; and 4) the bundle's quality and strength. Barriers identified included: 1) intervention-related issues (e.g., timing of trials, fear of adverse events), 2) communication and care coordination challenges, 3) knowledge deficits, 4) workload concerns, and 5) documentation burden. Despite these challenges, participants believed implementation ultimately benefited patients, improved interdisciplinary communication, and empowered nurses and other ICU team members.
  
  
  CONCLUSIONS
  In this study of the implementation of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle in a tertiary care setting, clear factors were identified that both advanced and impeded adoption of this complex intervention that requires interprofessional education, coordination, and cooperation. Focusing on these factors preemptively should enable a more effective and lasting implementation of the bundle and better care for critically ill patients. Lessons learned from this study will also help healthcare providers optimize implementation of the recent ICU pain, agitation, and delirium guidelines, which has many similarities but also some important differences as compared with the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle.
authors.affiliation: Center for Critical and Complex Care, The Ohio State University College of Nursing, Columbus, OH, USA. mbalas@unmc.edu
authors.forename: Michele C
authors.initials: MC
authors.lastname: Balas
authors.forename: William J
authors.initials: WJ
authors.lastname: Burke
authors.forename: David
authors.initials: D
authors.lastname: Gannon
authors.forename: Marlene Z
authors.initials: MZ
authors.lastname: Cohen
authors.forename: Lois
authors.initials: L
authors.lastname: Colburn
authors.forename: Catherine
authors.initials: C
authors.lastname: Bevil
authors.forename: Doug
authors.initials: D
authors.lastname: Franz
authors.forename: Keith M
authors.initials: KM
authors.lastname: Olsen
authors.forename: E Wesley
authors.initials: EW
authors.lastname: Ely
authors.forename: Eduard E
authors.initials: EE
authors.lastname: Vasilevskis
mesh_terms: D000046:Academic Medical Centers; D003422:Critical Care / Q000379:methods* / Q000458:organization & administration; D003693:Delirium / Q000517:prevention & control*; D004434:Early Ambulation / Q000379:methods*; D019317:Evidence-Based Medicine; D017144:Focus Groups; D019538:Health Care Surveys; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D007362:Intensive Care Units; D033183:Interdisciplinary Communication; D015146:Midwestern United States; D008991:Monitoring, Physiologic / Q000379:methods; D017410:Practice Guidelines as Topic; D016730:Program Development; D011446:Prospective Studies; D011595:Psychomotor Agitation / Q000517:prevention & control*; D012121:Respiration, Artificial; D015300:Ventilator Weaning