Behavioral Economic and Staffing Strategies To Increase Adoption of the ABCDEF Bundle in the ICU (BEST-ICU)

Project Summary Survivors of critical illness frequently experience profound physical, mental, and cognitive health impairments that are initiated and/or exacerbated by known racial and socioeconomic health disparities and outdated intensive care unit (ICU) mechanical ventilation and symptom management practices. This morbidity is potentially preventable through the application of the ABCDEF bundle; a multicomponent, evidence-based intervention to improve team-based care. While consistently proven safe and effective, national ABCDEF bundle performance remains unacceptably low as clinicians continue to struggle with multiple barriers to bundle delivery. The long-term goal of the proposed work is to develop pragmatic and sustainable strategies to increase the delivery of evidence-based practices that lead to improved care for critically ill adults across a variety of healthcare systems, particularly those serving populations with known health disparities (safety net hospitals). Our overall objective is to evaluate two strategies grounded in behavioral economic theory and implementation science to increase ABCDEF bundle adoption. The strategies being evaluated target a variety of ICU team members and known behavioral determinants of bundle performance. The proposed project includes two phases and four aims. In Phase 1 (UG3), we will work with the NIH’s Healthcare System Research Collaboratory Coordinating Center and our community partners to meet key milestones aimed at enhancing and finalizing the implementation strategies and research methods used to facilitate and evaluate the effectiveness of ABCDEF bundle adoption (UG3 Aim 1). In Phase 2 (UH3), we will conduct a pragmatic, stepped-wedge, cluster randomized hybrid type III effectiveness-implementation trial. After creating 6 matched pairs of 12 ICUs from 3 hospitals (N=8,100 patients on mechanical ventilation), we will randomly assign ICUs within each matched pair to receive either real-time audit and feedback (strategy A) or a Registered Nurse (RN) implementation facilitator (strategy B) and each pair to one of six wedges. The aims of the trial are to compare the effectiveness of real-time audit and feedback and RN implementation facilitator on ABCDEF bundle adoption (UH3 Aim 1; primary outcome) and clinical outcomes (i.e., duration of mechanical ventilation; ICU, hospital, and 30-day mortality; ICU and hospital length of stay; days with acute brain dysfunction; discharge disposition, psychoactive medication, and physical therapy utilization; and 30- day hospital readmission) (UH3 Aim 2). Finally, we will identify and describe key stakeholders’ experiences with, and perspectives on, the acceptability and impact on workload of the implementation strategies (UH3 Aim 3). We expect study results will impact the field by developing simple, yet effective, ways of accelerating the reliable uptake of a variety of evidence-based ICU interventions that will address known health disparities in the ICU and ultimately improve the care and outcomes of millions of critically ill adults annually.