Assess, Prevent, and Manage Pain; Both Spontaneous Awakening and Breathing Trials; Choice of Analgesia/Sedation; Delirium: Assess, Prevent, and Manage; Early Mobility; Family Engagement and Empowerment Bundle Implementation: Quantifying the Association of Access to Bundle-Enhancing Supplies and Equipment

Abstract

OBJECTIVES:. Describe the physical environment factors (i.e., availability, accessibility) of bundle-enhancing items and the association of physical environment with bundle adherence. DESIGN:. This multicenter, exploratory, cross-sectional study used data from two ICU-based randomized controlled trials that measured daily bundle adherence. Unit- and patient-level data collection occurred between 2011 and 2016. We developed hierarchical logistic regression models using Frequentist and Bayesian frameworks. SETTING:. The study included 10 medical and surgical ICUs in six academic medical centers in the United States. PATIENTS:. Adults with qualifying respiratory failure and/or septic shock (e.g., mechanical ventilation, vasopressor use) were included in the randomized controlled trials. INTERVENTIONS:. The Awakening and Breathing trial Coordination, Delirium assessment/management, Early mobility bundle was recommended standard of care for randomized controlled trial patients and adherence tracked daily. MEASUREMENTS AND MAIN RESULTS:. 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). Models included unit-level measures such as minimum and maximum distances to bundle-enhancing items and patient-level age, body mass index, and daily mechanical ventilation status. Some models suggested the following variables were influential: unit size (larger associated with decreased adherence), a standard walker (presence associated with increased adherence), and age (older associated with decreased adherence). In all cases, mechanical ventilation was associated with decreased bundle adherence. CONCLUSIONS:. Both unit- and patient-level factors were associated with full bundle and early mobility adherence. There is potential benefit of physical proximity to essential items for Awakening and Breathing trial Coordination, Delirium assessment/management, Early mobility bundle and early mobility adherence. Future studies with larger sample sizes should explore how equipment location and availability influence practice.