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that are initiated and/or exacerbated by known racial and socioeconomic health disparities and outdated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.
