Impact of ABCDE Bundle Implementation in the Intensive Care Unit on Specific Patient Costs

Abstract

Objectives:

To measure the impact of full versus partial ABCDE bundle implementation on specific cost centers and related resource utilization.

Design:

Retrospective cohort study.

Setting:

Two medical ICUs within Montefiore Health System (Bronx, NY).

Patients:

Four hundred and seventy-two mechanically ventilated patients admitted to the medical ICUs during a hospitalization which began and ended between January 1, 2013 and December 31, 2013.

Interventions:

The full (A)wakening, (B)reathing, (C)oordination, (D)elirium Monitoring/Management and (E)arly Mobilization bundle was implemented in the intervention ICU while a portion of the bundle (A, B, and D components) was implemented in the comparison ICU.

Measurements and Main Results:

Relative to the comparison ICU, implementation of the entire bundle in the intervention ICU was associated with a 27.3% (95% CI: 9.9%, 41.3%; P = 0.004) decrease in total hospital laboratory costs and a 2,888.6% (95% CI: 77.9%, 50,113.2%; P = 0.018) increase in total hospital physical therapy costs. Cost of total hospital medications, diagnostic radiology and respiratory therapy were unchanged. Relative to the comparison ICU, total hospital resource use decreased in the intervention ICU (incidence rate ratio [95% CI], laboratory: 0.68 [0.54, 0.87], P = 0.002; diagnostic radiology: 0.75 [0.59, 0.96], P = 0.020).

Conclusions:

Full ABCDE bundle implementation resulted in a decrease in total hospital laboratory costs and total hospital laboratory and diagnostic resource utilization while leading to an increase in physical therapy costs.

Keywords

critical care intensive care units early ambulation cost and cost analysis laboratories radiology

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References

Morandi

Brummel

Ely

. Sedation, delirium and mechanical ventilation: the “ABCDE” approach. Curr Opin Crit Care. 2011;17(1):43–49.

Morandi

Jackson

Ely

. Delirium in the intensive care unit. Int Rev Psychiatry. 2009;21(1):43–58.

Stevens

Dowdy

Michaels

Mendez-Tellez

Pronovost

Needham

. Neuromuscular dysfunction acquired in critical illness: a systematic review. Intensive Care Med. 2007;33(11):1876–1891.

Thomason

Shintani

Peterson

Pun

Jackson

Ely

. Intensive care unit delirium is an independent predictor of longer hospital stay: a prospective analysis of 261 non-ventilated patients. Crit Care. 2005;9(4): R375–R381.

Ely

Gautam

Margolin

, et al. The impact of delirium in the intensive care unit on hospital length of stay. Intensive Care Med. 2001;27(12):1892–1900.

Ely

Shintani

Truman

, et al. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA. 2004;291(14):1753–1762.

Garnacho-Montero

Madrazo-Osuna

Garcia-Garmendia

, et al. Critical illness polyneuropathy: risk factors and clinical consequences. A cohort study in septic patients. Intensive Care Med. 2001;27(8):1288–1296.

Iwashyna

Ely

Smith

Langa

. Long-term cognitive impairment and functional disability among survivors of severe sepsis. JAMA. 2010;304(16):1787–1794.

Jackson

Mitchell

Hopkins

. Cognitive functioning, mental health, and quality of life in ICU survivors: an overview. Anesthesiol Clin. 2011;29(4):751–764.

10.

Girard

Jackson

Pandharipande

, et al. Delirium as a predictor of long-term cognitive impairment in survivors of critical illness. Crit Care Med. 2010;38(7):1513–1520.

11.

Milbrandt

Deppen

Harrison

, et al. Costs associated with delirium in mechanically ventilated patients. Crit Care Med. 2004;32(4):955–962.

12.

Hsieh

Otusanya

Gershengorn

, et al. Staged implementation of awakening and breathing, coordination, delirium monitoring and management, and early mobilization bundle improves patient outcomes and reduces hospital costs. Crit Care Med. 2019;47(7):885-893.

13.

Collinsworth

Priest

Masica

. Evaluating the cost-effectiveness of the ABCDE bundle: impact of bundle adherence on inpatient and 1-year mortality and costs of care. Crit Care Med. 2020;48(12):1752–1759.

14.

Bakhru

McWilliams

Wiebe

Spuhler

Schweickert

. Intensive care unit structure variation and implications for early mobilization practices. An international survey. Ann Am Thorac Soc. 2016;13(9):1527–1537.

15.

Bakhru

Wiebe

McWilliams

Spuhler

Schweickert

. An environmental scan for early mobilization practices in U.S. ICUs. Crit Care Med. 2015;43(11):2360–2369.

16.

Deyo

Cherkin

Ciol

. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol. 1992;45(6):613–619.

17.

Zimmerman

Kramer

McNair

Malila

. Acute Physiology and Chronic Health Evaluation (APACHE) IV: hospital mortality assessment for today’s critically ill patients. Crit Care Med. 2006;34(5):1297–1310.

18.

Cost-to-Charge Ratio Files. Healthcare Cost and Utilization Project (HCUP) . Agency for Healthcare Research and Quality; 2019.

19.

Dalton

A study of charge compression in calculating DRG relative weights. RTI International; 2007.

20.

Ashenfelter

Card

. Using the longitudinal structure of earnings to estimate the effect of training programs. Revieconstat the Review of Economics and Statistics. 1985;67(4):648–660.

21.

Abadie

. Semiparametric difference-in-differences estimators. Rev Eco Stud. 2005;72:1–20.

22.

Angrist

Pischke

Jr . Mostly harmless econometrics: an empiricist’s companion . Princeton University Press; 2009.

23.

Dimick

Ryan

. Methods for evaluating changes in health care policy: the difference-in-differences approach. JAMA. 2014;312(22):2401–2402.

24.

Balas

Vasilevskis

Olsen

, et al. Effectiveness and safety of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle. Crit Care Med. 2014;42(5):1024–1036.

25.

Khan

Guerra

Khandji

Bauer

Claassen

Wunsch

. Frequency of acute changes found on head computed tomographies in critically ill patients: a retrospective cohort study. J Crit Care. 2014;29(5):884. e7-e12.

26.

Gilchrist

Asoh

Greenberg

. Atypical antipsychotics for the treatment of ICU delirium. J Intensive Care Med. 2012;27(6):354–361.

27.

Swan

Fitousis

Hall

Todd

Turner

. Antipsychotic use and diagnosis of delirium in the intensive care unit. Crit Care. 2012;16(3): R84.

28.

G Peitz

Sankaranarayanan

Balas

Olsen

. Awakening and breathing coordination, delirium monitoring and early mobility bundle in adult ICU patients: a preliminary cost analysis. Crit Care Med. 2014;18(suppl 1):P409.

29.

Lord

Mayhew

Korupolu

, et al. ICU early physical rehabilitation programs: financial modeling of cost savings. Crit Care Med. 2013;41(3):717–724.

30.

Devlin

Skrobik

Gelinas

, et al. Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Crit Care Med. 2018;46(9):e825–e873.

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