Staged Implementation of Awakening and Breathing, Coordination, Delirium Monitoring and Management, and Early Mobilization Bundle Improves Patient Outcomes and Reduces Hospital Costs

Design: Prospective cohort study.

Setting: Two medical ICUs within Montefiore Healthcare Center (Bronx, NY).

Patients: One thousand eight hundred fifty-five mechanically ventilated patients admitted to ICUs between July 2011 and July 2014.

Interventions: At baseline, spontaneous (B)reathing trials (B) were ongoing in both ICUs; in period 1, (A)wakening and (D)elirium (AD) were implemented in both full and partial bundle ICUs; in period 2, (E)arly mobilization and structured bundle (C)oordination (EC) were implemented in the full bundle (B-AD-EC) but not the partial bundle ICU (B-AD).

Measurements and Main Results: In the full bundle ICU, 95% patient days were spent in bed before EC (period 1). After EC was implemented (period 2), 65% of patients stood, 54% walked at least once during their ICU stay, and ICU-acquired pressure ulcers and physical restraint use decreased (period 1 vs 2: 39% vs 23% of patients; 30% vs 26% patient days, respectively; p < 0.001 for both). After adjustment for patient-level covariates, implementation of the full (B-AD-EC) versus partial (B-AD) bundle was associated with reduced mechanical ventilation duration (–22.3%; 95% CI, –22.5% to –22.0%; p < 0.001), ICU length of stay (–10.3%; 95% CI, –15.6% to –4.7%; p = 0.028), and hospital length of stay (–7.8%; 95% CI, –8.7% to –6.9%; p = 0.006). Total ICU and hospital cost were also reduced by 24.2% (95% CI, –41.4% to –2.0%; p = 0.03) and 30.2% (95% CI, –46.1% to –9.5%; p = 0.007), respectively.

Conclusions: In a clinical practice setting, the addition of (E)arly mobilization and structured (C)oordination of ABCDE bundle components to a spontaneous (B)reathing, (A)wakening, and (D) elirium management background led to substantial reductions in the duration of mechanical ventilation, length of stay, and cost.