Helping Older Persons Emerge Stronger

Study Overview
=================
Brief Summary
-----------------
Select Specialty, a national network of more than 100 LTACHs across the United States, has expressed the desire to adopt the ABCDEF bundle as a standard of care for its patients. As part of this initiative, Select first plans to conduct an ABCDEF bundle quality improvement project in one of its local hospitals. The overall purpose of this before-after study is to study prospectively the process and effects of implementing the ABCDEF bundle into the everyday care of patients requiring prolonged mechanical ventilation in the LTACH setting.

Detailed Description
-----------------
The 300,000 chronically critically ill patients each year who require prolonged mechanical ventilation (PMV)1,2 represent an ever-growing, extremely vulnerable, proportion of intensive care unit (ICU) survivors.3 The increasing number of these patients is an important factor in the expanded use of long-term acute care hospitals (LTACHs), centers that specialize in mechanical ventilation weaning and rehabilitation. The 412 LTACHs currently operated in the United States admit more than 130,000 patients annually and account for more than $5 billion in Medicare expenditures each year.4,5 Unfortunately, LTACH stays for patients requiring PMV are typically complicated and associated with a number of poor outcomes including very high one-year mortality rates (44-77%),6,7 severe and enduring brain dysfunction (i.e., coma and/or delirium), life-altering functional decline, substantial pain and suffering, caregiver burden and diminished quality of life.6-11 While returning home is often an important goal for patients and their families,3 this is a rare outcome in this population.11 Rather, patients requiring PMV often experience multiple transitions in care in the year following their original hospital admission (median of 4), which results in further costs and persistent, profound disability.9 Despite these disheartening findings, to date there is very limited scientific evidence available to help clinicians care for the chronically critically ill, particularly those requiring PMV in LTACHs. Chronically critically ill patients are generally older, sicker and have more comorbidities than their acutely ill counterparts.12 Importantly, they also suffer from much greater symptom burden, with up to 90% of patients experiencing at least one distressing symptom during the course of their illness (e.g., pain, dyspnea, weakness).13 While these symptoms are often thought of as unfortunate and inevitable consequences of critical illness,14 evidence suggests that the inappropriate management of these symptoms may actually be causal to the poor outcomes experienced by this group.15 For example, the results of numerous, well-designed, clinical trials conducted in the traditional ICU setting by our team and others suggest regular pain, agitation, and delirium assessment, prevention and treatment, coupled with strategies that decrease patients' exposure to sedative medications, support early mobilization, promote evidence-based mechanical ventilation discontinuation approaches, and actively engage and empower family members in patient care can positively affect important patient-centered outcomes (e.g., improved survival and physical/cognitive ability).16-26 One unifying method of implementing these evidence based interventions into everyday practice is consistent and reliable use of the ABCDEF bundle (i.e., Assess, prevent, and manage pain, Both Spontaneous Awakening Trials (SATs) & Spontaneous Breathing Trials (SBTs), Choice of analgesia and sedation, Delirium assess, prevent, and manage, Early mobility and exercise, and Family engagement and empowerment).27 Congruent with the Society of Critical Care Medicine's Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium and endorsed by a number of patient safety and quality organizations including the Institute for Healthcare Improvement and the Gordon and Betty Moore Foundation, the ABCDEF bundle is being actively implemented in ICUs throughout the world. The strength of evidence supporting the ABCDEF bundle, coupled with this strong implementation momentum, has prompted interest in the LTACH in applying the bundle into the everyday care of chronically critically ill patients who require mechanical ventilation. Select Specialty, a national network of more than 100 LTACHs across the United States, has expressed the desire to adopt the ABCDEF bundle as a standard of care for its patients. As part of this initiative, Select first plans to conduct an ABCDEF bundle quality improvement project in one of its local hospitals. The overall purpose of this before-after study is to study prospectively the process and effects of implementing the ABCDEF bundle into the everyday care of patients requiring prolonged mechanical ventilation in the LTACH setting. Specifically the study's aims are to: Aim 1: Identify facilitators and barriers to successful ABCDEF bundle implementation in the LTACH setting. Aim 2: Compare the symptom experience (e.g., pain, agitation, anxiety, fatigue, shortness of breath, restlessness, sadness, hunger, fear, thirst, confusion sedative medication exposure) of patients receiving usual LTACH care (during months 1-4.5) to those treated with the ABCDEF bundle (during months 4.5-9). Aim 3. Evaluate the impact ABCDEF bundle implementation has on safety (i.e., new pneumonias, device self-removal) and patient-centered outcomes (i.e., delirium/coma free days, weaning duration, tracheostomy removal , mortality, depression, post-traumatic stress disorder, functional and cognitive ability, discharge disposition, opioid and benzodiazepine withdrawal rates, and quality of life) of patients receiving usual LTACH care (during months 1-4.5) to those treated with the ABCDEF bundle (during months 4.5-9). To complete these aims the investigators will administer an on-line survey and conduct focus group interviews with LTACH staff before and after the ABCDEF bundle is implemented into everyday care. Over the course of a nine month period, the investigators will also consent and enroll 81 patients who require mechanical ventilation at the time of LTACH admission. These patients will undergo daily, in-person symptom assessment using valid and reliable screening tools. Finally, medical record reviews and brief patient interviews will be conducted to obtain data on our outcomes of interest.

Official Title
-----------------
Helping Older Persons Emerge Stronger (HOPES) After Intensive Care Unit Admission

Conditions
-----------------
Delirium, Ventilators, Pain, Agitation, Anxiety

Intervention / Treatment
-----------------
* Other: Survey
* Other: interview


Participation Criteria
=================
Eligibility Criteria
-----------------
Aim 1: Inclusion • All full and part-time Registered Nurses, attending physicians, respiratory therapists, pharmacists, and physical/occupational/speech therapists who regularly care for patients requiring prolonged mechanical ventilation in the LTACH setting Exclusion • None Aims 2 and 3: Inclusion >18 years old Admitted to the LTACH with a tracheostomy Require mechanical ventilation > 8 hours a day upon LTACH admission English speaking Exclusion Criteria: Severe neurologic deficits defined as coma (i.e., Richmond Agitation Sedation Score < -4 or -5 due to stroke, intracranial hemorrhage, cranial trauma, malignancy, anoxic brain injury, or cerebral edema) Inability to obtain informed consent from the patient's legally authorized representative (LAR) within 72 hours of meeting all inclusion criteria Chronic ventilator dependence that is deemed not weanable by admitting LTACH physician.

Ages Eligible for Study
-----------------
Minimum Age: 18 Years

Sexes Eligible for Study
-----------------
All

Accepts Healthy Volunteers
-----------------
No

Study Plan
=================
How is the study designed?
-----------------

Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Healthcare providers<br>All healthcare providers working in the participating LTACH will be asked to complete 2 surveys and invited to participate in focus group meetings | Other: Survey<br>* Administered to healthcare providers<br>* Other names: Focus group interviews;Other: interview<br>* Administered to patients and LAR (i.e., interviews)<br>* Other names: Medical record review;|
| Patients<br>81 LTACH patients will be enrolled over the course of a 9 month period. Each patient and their LAR will be interviewed at the time of LTACH admission to garner information about their pre hospitalization physical, functional, and cognitive health status. Each day enrolled patients will undergo daily symptom assessments and medical record reviews. At the time of LTACH discharge all enrolled patients will be interviewed again to garner information about their discharge physical, functional, and cognitive health status. | Other: interview<br>* Administered to patients and LAR (i.e., interviews)<br>* Other names: Medical record review;|

What is the study measuring?
-----------------
Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Facilitators/Barriers to successful ABCDEF bundle implementation in the LTACH setting | Achieved through surveys and focus groups of LTACH providers | 9 months | 
| Pain | As measured by numeric rating scale of behavioral pain sclae | 9 months | 
| All cause mortality |  | 9 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Level of Arousal | As measured by Richmond Agitation and Sedation Scale (RASS) | 9 months | 
| Delirium | As measured by Confusion Assessment Method ICU (CAM-ICU) | 9 months | 
| Anxiety Anxiety | As measured by Visual Analog Scale | 9 months | 
| Other Symptoms | As measured by Patient Symptom Survey | 9 month | 
| Opioid Withdrawal | As measured by Clinical Opiate WIthdrawl Scale | 9 months | 
| Benzodiazepine Withdrawal | As measured by Clinical Institute Withdrawal Assessment Scale-Benzodiazepines | 9 months | 
| Delirium/Coma free days | As measured by CAM ICU and RASS | 9 months | 
| Weaning duration |  | 9 months | 
| New Pneumonia |  | 9 months | 
| Device self-removal |  | 9 months | 
| Tracheostomy removal |  | 90 months | 
| Depression | As measured by Hospital Anxiety and Depression Scale | 90 months | 
| Post Traumatic Stress Disorder | As measured by Impact of Event Scale | 9 months | 
| Functional ability | As measured by Functional Status Score ICU, KATZ ADL, LAWTON IADL | 9 months | 
| Cognitive ability | As measure by Mini Mental State Exam | 9 months | 
| Quality of Life | As measured by SF 36 | 9 months |