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Original Research |

Identifying barriers to delivering the ABCDE bundle to minimize adverse outcomes for mechanically ventilated patients: A systematic review

Deena Kelly Costa, PhD, RN; Matthew White; Emily Ginier, MLIS; Milisa Manojlovich, PhD, RN, CCRN; Sushant Govindan, MD; Theodore J. Iwashyna, MD, PhD; Anne E. Sales, PhD, RN
Author and Funding Information

Fundingand disclosures: This project was supported by grant number K08HS024552 from the Agency for Healthcare Research and Quality. Funding for this work was also provided by the Veterans Health Administration's Office of Analytics and Business Intelligence (OABI). The content is solely the responsibility of the authors and does not necessarily reflect the official views of the Agency for Healthcare Research and Quality. Dr. Deena Costa also receives in-kind research support from the Michigan Health and Hospital Association (MHA) Keystone Center. This work does not necessarily represent the views of the US Government or the Department of Veterans Affairs. We report no other conflicts of interests or disclosures.

This work was presented as a poster presentation at AcademyHealth Annual Research Meeting, June 2015 in Orlando Florida.

1University of Michigan, School of Nursing, Ann Arbor MI

2University of Michigan Taubman Health Sciences Library, Ann Arbor MI

3University of Michigan Medical School, Division of Pulmonary and Critical Care Medicine, Ann Arbor, MI

4VA Center for Clinical Management Research, Ann Arbor MI

5University of Michigan Medical School, Department of Learning Health Sciences, Ann Arbor MI

Corresponding author: Deena Kelly Costa PhD, RN 400 North Ingalls St, Room 4351 Ann Arbor MI, 48109.


Copyright 2017, American College of Chest Physicians. All Rights Reserved.


Chest. 2017. doi:10.1016/j.chest.2017.03.054
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Published online

Abstract

Background  Improved outcomes are associated with the Awakening, Breathing Coordination, Delirium and Early mobility/exercise (ABCDE) bundle; however, implementation issues are common. As yet, no study has integrated the barriers to ABCDE to provide an overview of reasons for less successful efforts. The purpose of this review was to identify and catalog the barriers to ABCDE delivery based on a widely used implementation framework, and provide a resource to guide clinicians in overcoming barriers to implementation.

Methods  We searched MEDLINE via PubMed, CINAHL, and Scopus for original research from January 1, 2007 to August 31, 2016 that identified barriers to ABCDE implementation for adult intensive care unit (ICU) patients. Two reviewers independently reviewed studies, extracted barriers and conducted thematic content analysis of the barriers, guided by the Consolidated Framework for Implementation Research. Discrepancies were discussed and consensus achieved.

Results  Our electronic search yielded 1908 articles. After applying our inclusion/exclusion criteria, we included 49 studies. We conducted thematic content analysis of the 107 barriers and identified 4 classes of ABCDE barriers: 1) patient-related (i.e. patient instability and safety concerns); 2) clinician-related (i.e. lack of knowledge, staff safety concerns); 3) protocol-related (i.e. unclear protocol criteria, cumbersome protocols to use); and—not previously identified in past reviews—4) ICU contextual barriers (i.e. interprofessional team care coordination).

Conclusions  We provide the first systematic differential diagnosis of barriers to ABCDE delivery, moving beyond the conventional focus on patient-level factors. Our analysis offers a differential diagnosis checklist for clinicians planning ABCDE implementation to improve patient care and outcomes.


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