Improving ABCDEF Bundle Compliance and Clinical Outcomes in the ICU: Randomized Control Trial to Assess the Impact of Performance Measurement, Feedback, and Data Literacy Training

ABSTRACT

OBJECTIVES: Describe the effects of data literacy training and continuous performance reports on ICU staff compliance with the 6-element ICU quality bundle approach known as the ABCDEF (A–F) bundle and patient outcomes. DESIGN: Stepped-wedge cluster randomized trial conducted during an institutional A–F bundle implementation program. SETTING: Single-center study conducted in eight adult ICUs. PATIENTS Adult patients admitted for at least 24 hours, not undergoing active withdrawal of life support or palliative care. INTERVENTIONS: Four ICUs in the intervention group received bundle-related staff education, data literacy training, and weekly bundle performance reports during the 12-month study period. The four ICUs in the nonintervention group received none of these interventions. Bundle compliance and patient outcomes were tracked, including ICU and hospital mortality, transfer and discharge, discharge disposition, mechanical ventilation, and ICU delirium. MEASUREMENT AND RESULTS: In the intervention group, staff education alone increased bundle compliance from 9% to 16% (p < 0.0001);data literacy training further increased compliance from 16% to 21% (p = 0.03). This improvement was sustained throughout the study period including the onset of the COVID-19 pandemic and was greater than improvement in the nonintervention group (p < 0.001). Full A–F bundle compliance was associated with a lower likelihood of next-day ICU and hospital mortality, discharge to a facility other than home, and was associated with a higher likelihood of next-day extubation in patients. Next-day ICU and hospital discharge likelihood decreased, and delirium frequency was not affected. CONCLUSIONS: This is the first study demonstrating that the combination of staff education, data literacy training, and access to performance data improves A–F bundle compliance, sustains performance, and improves ICU patient outcomes (ICU and hospital mortality, mechanical ventilation duration, and home discharge rates). In contrast to previous studies, increased bundle compliance did not hasten ICU or hospital discharges or reduce delirium frequency in patients.