title: ABCDE, but in that order? A cross-sectional survey of Michigan intensive care unit sedation, delirium, and early mobility practices.
abstract: BACKGROUND
  A bundled approach to intensive care unit (ICU) care known as "Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility" (ABCDE) has been proposed, with evidence supporting individual interventions as well as the bundle as a whole. Few data exist on the bundle's implementation and efficacy in community practice.
  
  
  OBJECTIVE
  To evaluate self-reported rates of implementation of ABCDE components and their association with outcomes in a state-wide quality improvement collaborative.
  
  
  METHODS
  A written survey was administered to representatives attending the 2012 annual meeting of the Michigan Health and Hospital Association's Keystone ICU collaborative. Respondents reported on their practices regarding spontaneous awakening trials, delirium assessments, and early mobility.
  
  
  RESULTS
  There were 212 respondents, a 76% response rate. Wide variation in focus was noted across the assessed components of ABCDE. Only 12% reported having implemented routine spontaneous awakening trials and delirium assessments as well as early mobility, 36% reported not having early mobility as an active goal in their units (nonmovers), and 52% reported attempts at early mobility without both routine sedation interruption and delirium screening implementation. In adjusted models, those who implemented exercise with sedation interruption and delirium screening were 3.5 (95% confidence interval, 1.4-8.6) times more likely to achieve higher levels of exercise in ventilated patients than those who implemented exercise without both sedation interruption and delirium screening.
  
  
  CONCLUSIONS
  There is incomplete penetrance of aspects of ABCDE across ICUs in this highly motivated statewide quality improvement collaborative. Yet, implementation of exercise in the context of both sedation interruption and delirium screening was associated with improved self-reported mobility outcomes. Effective knowledge translation and implementation strategies may offer substantial benefits to ICU patients.
authors.affiliation: 1 Department of Internal Medicine, University of Michigan, Ann Arbor.
authors.forename: Melissa A
authors.initials: MA
authors.lastname: Miller
authors.affiliation: 1 Department of Internal Medicine, University of Michigan, Ann Arbor.
authors.forename: Sushant
authors.initials: S
authors.lastname: Govindan
authors.affiliation: 2 Michigan Health and Hospital Association Keystone Center, Lansing, Michigan; and.
authors.forename: Sam R
authors.initials: SR
authors.lastname: Watson
authors.affiliation: 1 Department of Internal Medicine, University of Michigan, Ann Arbor.
authors.forename: Robert C
authors.initials: RC
authors.lastname: Hyzy
authors.affiliation: 1 Department of Internal Medicine, University of Michigan, Ann Arbor.|3 Center for Clinical Management Research, Ann Arbor Veterans Affairs Healthcare System, Ann Arbor, Michigan.
authors.forename: Theodore J
authors.initials: TJ
authors.lastname: Iwashyna
mesh_terms: D003422:Critical Care / Q000592:standards*; D003430:Cross-Sectional Studies; D003693:Delirium / Q000517:prevention & control*; D006801:Humans; D007362:Intensive Care Units / Q000592:standards*; D016015:Logistic Models; D008824:Michigan; D008875:Middle Aged; D051346:Mobility Limitation; D015999:Multivariate Analysis; D058996:Quality Improvement / Q000592:standards*; D057566:Self Report
keywords: critical care; delirium; mobility limitation