Investigators of the BEST-ICU study, an NIH collaborative trial, seek to develop pragmatic and sustainable strategies to increase the delivery of evidence-based practices that lead to improved care for adults with serious illness, particularly for health systems serving populations with known health disparities.
The BEST-ICU trial recently received approval from the NIH Collaborative Coordinating Center for Pragmatic Trials to move from the planning phase to the implementation phase of the study.
Survivors of critical illness often experience profound physical, mental, and cognitive health declines that are initiated and/or exacerbated by known racial and socioeconomic health disparities and outdated mechanical ventilation and symptom management practices in the intensive care unit (ICU).
This morbidity is potentially preventable through the application of the ABCDEF package, a multicomponent evidence-based intervention to improve team-based care.
The ABCDEF package includes: TOEvaluate, prevent and control pain. BBoth spontaneous awakening trials (SAT) and spontaneous breathing trials (SBT), CChoice of analgesia and sedation, Delirium: assess, prevent and manage, myEarly mobility and exercise, and FFamily commitment and empowerment.
While consistently shown to be safe and effective, national performance of the ABCDEF bundles remains unacceptably low as clinicians continue to struggle with multiple barriers to bundle implementation. The long-term goal of BEST-ICU is to develop pragmatic and sustainable strategies to increase implementation of evidence-based practices that lead to improved care for seriously ill adults across a variety of healthcare systems, particularly those serving populations with known health disparities, such as safety-net hospitals. The overall goal of BEST-ICU is to evaluate two strategies grounded in behavioral economic theory and implementation science to increase adoption of the ABCDEF bundles. The strategies being evaluated target a variety of ICU team members and known behavioral determinants of bundle performance.
In a video conversation with the NIH Collaboratory, the study leaders described their efforts. “This is a set of practices that we do in the ICU to really address what we believe is an epidemic of post-intensive care survival issues, both cognitive and functional,” explained Ed Vasilevskis, MD, MPH, chief of the Division of Hospital Medicine in the Department of Medicine at the University of Wisconsin School of Medicine and Public Health. “This is a set of practices that are done in the ICU. They are supported by guidelines and involve using strategies to reduce the amount of time on mechanical ventilation, stopping sedation practices that patients receive, and closely monitoring pain and sedation.”
The trial consists of two specific interventions, Vasilevskis explained. One is the use of a real-time audit and feedback dashboard, which requires the use of information from the electronic health record. “Of course, every institution is built on Epic, but as you dig deeper, you see that not all electronic health records are designed exactly the same. The data elements are in different areas, and building the dashboard requires a lot of different people and moving parts, so it’s been a real challenge, but we saw that using informatics nurses was critical to our ability to cross the finish line.”
“This study has been a dream of mine,” said Michele Balas, Ph.D., RN, associate dean for research and the Dorothy Hodges Olson Distinguished Professor of Nursing in the College of Nursing at the University of Nebraska Medical Center. “One of the intervention arms, as Ed said, involves the electronic dashboard derived from the electronic medical record, but the other arm involves adding an additional registered nurse to the staff in the intensive care unit to help train, facilitate, and assist providers in delivering that hands-on care that critically ill patients need. My hypothesis is that both will be better than what we’re doing for patients right now, but I’m really interested to see if there will be benefits and what they will be in changing that care delivery model. It’s really important right now, particularly with the staffing shortages and severe burnout that ICU nurses and physicians and other members of our important interprofessional teams are facing.”
“There is a huge gap between our intentions and what we actually do in ICUs,” Vasilevskis added. “We all want to provide the best care to every single one of our patients, but it’s difficult to do so, so we are really trying to develop strategies to move from intention to reality in terms of providing the best care to every single patient every single time.”
