title: Effectiveness and safety of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle.
abstract: OBJECTIVE
  The debilitating and persistent effects of ICU-acquired delirium and weakness warrant testing of prevention strategies. The purpose of this study was to evaluate the effectiveness and safety of implementing the Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility bundle into everyday practice.
  
  
  METHODS
  Eighteen-month, prospective, cohort, before-after study conducted between November 2010 and May 2012.
  
  
  METHODS
  Five adult ICUs, one step-down unit, and one oncology/hematology special care unit located in a 624-bed tertiary medical center.
  
  
  METHODS
  Two hundred ninety-six patients (146 prebundle and 150 postbundle implementation), who are 19 years old or older, managed by the institutions' medical or surgical critical care service.
  
  
  METHODS
  Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility bundle.
  
  
  RESULTS
  For mechanically ventilated patients (n = 187), we examined the association between bundle implementation and ventilator-free days. For all patients, we used regression models to quantify the relationship between Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility bundle implementation and the prevalence/duration of delirium and coma, early mobilization, mortality, time to discharge, and change in residence. Safety outcomes and bundle adherence were monitored. Patients in the postimplementation period spent three more days breathing without mechanical assistance than did those in the preimplementation period (median [interquartile range], 24 [7-26] vs 21 [0-25]; p = 0.04). After adjusting for age, sex, severity of illness, comorbidity, and mechanical ventilation status, patients managed with the Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility bundle experienced a near halving of the odds of delirium (odds ratio, 0.55; 95% CI, 0.33-0.93; p = 0.03) and increased odds of mobilizing out of bed at least once during an ICU stay (odds ratio, 2.11; 95% CI, 1.29-3.45; p = 0.003). No significant differences were noted in self-extubation or reintubation rates.
  
  
  CONCLUSIONS
  Critically ill patients managed with the Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility bundle spent three more days breathing without assistance, experienced less delirium, and were more likely to be mobilized during their ICU stay than patients treated with usual care.
authors.affiliation: 1Center for Critical and Complex Care, The Ohio State University, College of Nursing, Columbus, OH. 2Department of Medicine, Division of General Internal Medicine and Public Health, Section of Hospital Medicine, Vanderbilt University, Nashville, TN. 3Center for Health Services Research, Vanderbilt University, Nashville, TN. 4Geriatric Research, Education, and Clinical Center, Tennessee Valley VA, Nashville, TN. 5Department of Pharmacy Practice, University of Nebraska Medical Center, College of Pharmacy, Omaha, NE. 6Department of Pharmaceutical and Nutrition Care, The Nebraska Medical Center, Omaha, NE. 7Department of Biostatistics, University of Nebraska Medical Center, College of Public Health, Omaha, NE. 8Department of Adult Health and Illness, University of Nebraska Medical Center, College of Nursing, Omaha, NE. 9Division of Pulmonary, Critical Care, Sleep, and Allergy, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE. 10Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE. 11Department of Surgery, University of Nebraska Medical Center, Omaha, NE. 12Department of Adult Critical Care Services, The Nebraska Medical Center, Omaha, NE. 13Department of Nursing Research and Quality Outcomes, The Nebraska Medical Center, Omaha, NE. 14Department of Respiratory Care, The Nebraska Medical Center, Omaha, NE. 15Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University, Nashville, TN. 16Department of Psychiatry, University of Nebraska Medical Center, Omaha, NE.
authors.forename: Michele C
authors.initials: MC
authors.lastname: Balas
authors.forename: Eduard E
authors.initials: EE
authors.lastname: Vasilevskis
authors.forename: Keith M
authors.initials: KM
authors.lastname: Olsen
authors.forename: Kendra K
authors.initials: KK
authors.lastname: Schmid
authors.forename: Valerie
authors.initials: V
authors.lastname: Shostrom
authors.forename: Marlene Z
authors.initials: MZ
authors.lastname: Cohen
authors.forename: Gregory
authors.initials: G
authors.lastname: Peitz
authors.forename: David E
authors.initials: DE
authors.lastname: Gannon
authors.forename: Joseph
authors.initials: J
authors.lastname: Sisson
authors.forename: James
authors.initials: J
authors.lastname: Sullivan
authors.forename: Joseph C
authors.initials: JC
authors.lastname: Stothert
authors.forename: Julie
authors.initials: J
authors.lastname: Lazure
authors.forename: Suzanne L
authors.initials: SL
authors.lastname: Nuss
authors.forename: Randeep S
authors.initials: RS
authors.lastname: Jawa
authors.forename: Frank
authors.initials: F
authors.lastname: Freihaut
authors.forename: E Wesley
authors.initials: EW
authors.lastname: Ely
authors.forename: William J
authors.initials: WJ
authors.lastname: Burke
mesh_terms: D000328:Adult; D000368:Aged; D002985:Clinical Protocols; D015331:Cohort Studies; D003422:Critical Care / Q000379:methods*; D003693:Delirium / Q000628:therapy*; D015444:Exercise; D005260:Female; D006801:Humans; D006993:Hypnotics and Sedatives / Q000627:therapeutic use*; D007103:Immobilization / Q000009:adverse effects* / Q000502:physiology; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012044:Regression Analysis; D012121:Respiration, Artificial / Q000009:adverse effects*; D016896:Treatment Outcome; D015300:Ventilator Weaning / Q000379:methods*
chemical_list: D006993:Hypnotics and Sedatives