Although growing evidence supports the safety and effectiveness of the ABCDEF bundle (A, assess, prevent, and manage pain; B, both spontaneous awakening and spontaneous breathing trials; C, choice of ...analgesic and sedation; D, delirium: assess, prevent, and manage; E, early mobility and exercise; and F, family engagement and empowerment), intensive care unit providers often struggle with how to reliably and consistently incorporate this interprofessional, evidence-based intervention into everyday clinical practice. Recently, the Society of Critical Care Medicine completed the ICU Liberation ABCDEF Bundle Improvement Collaborative, a 20-month, nationwide, multicenter quality improvement initiative that formalized dissemination and implementation strategies and tracked key performance metrics to overcome barriers to ABCDEF bundle adoption. The purpose of this article is to discuss some of the most challenging implementation issues that Collaborative teams experienced, and to provide some practical advice from leading experts on ways to overcome these barriers.
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Dostopno za:
DOBA, IZUM, KILJ, NUK, OILJ, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK, VSZLJ
OBJECTIVE:Decades-old, common ICU practices including deep sedation, immobilization, and limited family access are being challenged. We endeavoured to evaluate the relationship between ABCDEF bundle ...performance and patient-centered outcomes in critical care.
DESIGN:Prospective, multicenter, cohort study from a national quality improvement collaborative.
SETTING:68 academic, community, and federal ICUs collected data during a 20-month period.
PATIENTS:15,226 adults with at least one ICU day.
INTERVENTIONS:We defined ABCDEF bundle performance (our main exposure) in two ways1) complete performance (patient received every eligible bundle element on any given day) and 2) proportional performance (percentage of eligible bundle elements performed on any given day). We explored the association between complete and proportional ABCDEF bundle performance and three sets of outcomespatient-related (mortality, ICU and hospital discharge), symptom-related (mechanical ventilation, coma, delirium, pain, restraint use), and system-related (ICU readmission, discharge destination). All models were adjusted for a minimum of 18 a priori determined potential confounders.
MEASUREMENTS AND RESULTS:Complete ABCDEF bundle performance was associated with lower likelihood of seven outcomeshospital death within 7 days (adjusted hazard ratio, 0.32; CI, 0.17–0.62), next-day mechanical ventilation (adjusted odds ratio AOR, 0.28; CI, 0.22–0.36), coma (AOR, 0.35; CI, 0.22–0.56), delirium (AOR, 0.60; CI, 0.49–0.72), physical restraint use (AOR, 0.37; CI, 0.30–0.46), ICU readmission (AOR, 0.54; CI, 0.37–0.79), and discharge to a facility other than home (AOR, 0.64; CI, 0.51–0.80). There was a consistent dose-response relationship between higher proportional bundle performance and improvements in each of the above-mentioned clinical outcomes (all p < 0.002). Significant pain was more frequently reported as bundle performance proportionally increased (p = 0.0001).
CONCLUSIONS:ABCDEF bundle performance showed significant and clinically meaningful improvements in outcomes including survival, mechanical ventilation use, coma, delirium, restraint-free care, ICU readmissions, and post-ICU discharge disposition.
The ABCDEF bundle (A, assess, prevent, and manage pain; B, both spontaneous awakening and spontaneous breathing trials; C, choice of analgesic and sedation; D, delirium: assess, prevent, and manage; ...E, early mobility and exercise; and F, family engagement and empowerment) improves intensive care unit patient-centered outcomes and promotes interprofessional teamwork and collaboration. The Society of Critical Care Medicine recently completed the ICU Liberation ABCDEF Bundle Improvement Collaborative, a 20-month, multicenter, national quality improvement initiative that formalized dissemination and implementation strategies to promote effective adoption of the ABCDEF bundle. The purpose of this article is to describe 8 of the most frequently asked questions during the Collaborative and to provide practical advice from leading experts to other institutions implementing the ABCDEF bundle.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, OILJ, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK, VSZLJ
In regions plagued by reoccurring periods of war, violence and displacement, how does past exposure to violence affect altruism toward members of different ethnic or religious groups? Drawing on ...theories of empathy-driven altruism in psychology, this article proposes that violence can increase individuals’ capacity to empathize with others, and that empathy born of violence can in turn motivate helping behavior across group boundaries. This hypothesis is tested using data on the hosting behavior of roughly 1,500 Liberians during the 2010–11 Ivorian refugee crisis in eastern Liberia, a region with a long history of cross-border, inter-ethnic violence. Consistent with its theoretical predictions, the study finds that those who experienced violence during the Liberian civil war host greater numbers of refugees, exhibit stronger preferences for distressed refugees and less bias against outgroup refugees, and host a higher proportion of non-coethnic, non-coreligious and distressed refugees. These findings suggest that violence does not necessarily lead to greater antagonism toward outgroups, as is often assumed, and that in some circumstances it can actually promote inter-group co-operation.
What is the legacy of war, violence, and displacement on altruism toward diverse populations suffering similar hardships today? Prior research suggests these hardships have the potential to increase ...empathy that can in turn motivate altruism across identity boundaries. We test this hypothesis using survey data collected in 2017 from over 2,000 Syrians living in rebel-held regions where many internally displaced persons (IDPs) sought refuge. We find that Syrians previously exposed to violence were more likely to host IDPs. Using a conjoint experiment to measure hosting preferences over different types of IDPs, we show that these individuals also preferred to host sick and vulnerable IDPs and outgroup IDPs from the Kurdish ethnic minority. However, they were less likely to host IDPs from the Christian minority, possibly due to their association with the government. These results suggest that empathy and politics both play an important role in shaping the relationship between violence, altruism, and intergroup behavior during conflict.
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