Clinicians' perceptions on implementation strategies used to facilitate ABCDEF bundle adoption: A multicenter survey

Abstract

Background: Intensive care unit (ICU) clinicians struggle to routinely implement the ICU Liberation bundle (ABCDEF bundle). As a result, critically ill patients experience increased risk of morbidity and mortality. Despite extensive research related to the barriers and facilitators of bundle use, little is known regarding which implementation strategies are used to facilitate its adoption and sustainability.

Objectives: To identify implementation strategies used to increase adoption of the ABCDEF bundle and how those strategies are perceived by end-users (i.e., ICU clinicians) related to their helpfulness, acceptability, feasibility, and cost.

Methods: We conducted a national, cross-sectional survey of ICU clinicians from the 68 ICU sites that previously participated in the Society of Critical Care Medicine's ICU Liberation Collaborative. The survey was structured using the 73 Expert Recommendations for Implementing Change (ERIC) implementation strategies. Surveys were delivered electronically to site contacts.

Results: Nineteen ICUs (28%) returned completed surveys. Sites used 63 of the 73 ERIC implementation strategies, with frequent use of strategies that may be readily available to clinicians (e.g., providing educational meetings or ongoing training), but less use of strategies that require changes to well-established organizational systems (e.g., alter incentive allowance structure). Overall, sites described the ERIC strategies used in their implementation process to be moderately helpful (mean score >3<4 on a 5-point Likert scale), somewhat acceptable and feasible (mean score >2<3), and either not-at-all or somewhat costly (mean scores >1<3).

Conclusions: Our results show a potential over-reliance on accessible strategies and the possible benefit of unused ERIC strategies related to changing infrastructure and utilizing financial strategies.

Keywords: ABCDEF Bundle; ERIC; ICU; ICU Clinicians; ICU Liberation Bundle; Intensive Care Unit; Perceptions; implementation outcomes; implementation science; implementation strategies; mechanical ventilation; multidisciplinary.