Landmark UNMC research studies ABC’s of ICU care

Registered nurse Michele Balas, PhD, knows firsthand – and research has shown – that ICU patients fare better when health care teams implement evidence-based interventions every day.

These basic interventions range from assessing the patient’s pain to interrupting the use of sedation to increasing their mobility.

Now – in a landmark study for UNMC – Dr. Balas leads the med center’s first multisite, PCORnet® Study to assess strategies on how best to implement these evidence-based practices, known as the ABCDEF Bundle.

“The ABCDEF Bundle is considered the standard of care and should be given to every single patient, every single day in the ICU whether or not they are on the ventilator,” said Dr. Balas, associate dean of research and the Dorothy Hodges Olson Distinguished Professor of Nursing in the UNMC College of Nursing.

Still, amid workforce shortages, the longtime ICU nurse knows that doesn’t always happen – even among hospital systems and care teams with the best intentions.

She also knows one of the most common complications among hospitalized older adults is delirium. In the past, she said, delirium or acute confusion has been dismissed as being normal or age-related, but “we now know a single episode of acute confusion in the hospital elevates your risk for long-term cognitive impairment that can be as severe as dementia or traumatic brain injury. It’s not a single event.”

The good news, she said, is the interventions that make up the ABCDEF Bundle have proven effective in optimizing an ICU patient’s recovery and outcomes, and she’s determined to prove how best to implement the bundle on a broad scale.

Funded by the National Institutes of Health’s National Heart Lung Blood Institute and the National Institute of Nursing Research, Dr. Balas is leading a five-year study that involves mechanically ventilated ICU patients at Nebraska Medicine, The Ohio State University Wexner Medical Center and the University of Iowa Hospitals and Clinics.

Out of 12 participating ICUs, six units will implement and track implementation of the bundle on every patient via an electronic dashboard. (Green indicates the lifesaving intervention already was done that day; yellow means there’s still time to make it happen; red means it did not get done.) Meanwhile, six other ICUs will have one extra registered day nurse assigned to the ICU to “help in anyway needed to make the bundle come to life,” Dr. Balas said.

ICU data will be collected until early 2027 and then analyzed to determine what method works best to get evidence-based research – in this case the effective but underutilized ABCDEF Bundle – more quickly into clinical practice.

“We’re collecting so much data,” Dr. Balas said. “And I know we couldn’t do the study without the resources available through the PCORnet ecosystem.”

The med center’s involvement with national networks and ability to serve as a data coordinating center is notable, said Carol Geary, PhD, assistant professor in pathology/microbiology and UNMC PCORnet principal investigator, and “shows that UNMC is capable of playing in the research big leagues.”

She encourages other UNMC researchers to pursue clinical studies large enough to answer questions that can improve patient-centered outcomes. “We want people to say, ‘I could do that too.’”

The PCORnet® Study-designation denotes the study is powered by PCORnet, the National Patient-Centered Clinical Research Network, which is designed to improve the nation’s capacity to conduct health research and has been developed with funding from the Patient-Centered Outcomes Research Institute.

According to Dr. Geary, the study is an example of implementation science. “This is an important study for UNMC, the college of nursing and patient care and can help move evidence-based research into routine health care,” she said.

It’s also a continuation of earlier UNMC and Nebraska Medicine studies, Dr. Balas said, that led to the ABCDEF Bundle becoming the standard of care. “If you have a loved one who is in the ICU – in any hospital, in any country – you should expect that they get the ABCDEF Bundle. It is considered standard of care and what every patient should get.”

And Dr. Balas expects her latest study to inform hospital systems and health care teams on how best to make that happen each day. “I’m in it to improve patient care and patient-centered outcomes,” she said.