The ABCDEF Bundle in Critical Care

Abstract

The ABCDEF bundle represents an evidence-based guide for clinicians to approach the organizational changes needed for optimizing intensive care unit patient recovery and outcomes. This article reviews the core evidence and features behind the ABCDEF bundle. The bundle has individual components that are clearly defined, flexible to implement, and help empower multidisciplinary clinicians and families in the shared care of the critically ill. The ABCDEF bundle helps guide well-rounded patient care and optimal resource utilization resulting in more interactive intensive care unit patients with better controlled pain, who can safely participate in higher-order physical and cognitive activities at the earliest point in their critical illness.

Keywords: Analgesia; Delirium; Early mobility; Intensive care unit; Pain; Sedation; Spontaneous awakening trials; Spontaneous breathing trials.

Figure 1

Factors related to Hospitalization-Associated disability Data from Covinsky KE, Pierluissi E, Johnston CB. Hospitalization-associated disability: "She was probably able to ambulate, but I'm not sure". JAMA. 2011 Oct 26;306(16):1782–93. doi: 10.1001/jama.2011.1556.

Figure 2

Clinical Pain Observational Tool (CPOT) and Behavioral Pain Scale (BPS) Adapted from Payen JF, Bru O, Bosson JL, et al Assessing pain in critically ill sedated patients by using a behavioral pain scale Crticial Care Med. 2001 Dec;29(12):2258–63; with permission.

Figure 3

“Wake up and Breath” Protocol: Spontaneous Awakening Trials (SATs) with Spontaneous Breathing Trials © 2008 Vanderbilt University. All rights reserved

Figure 4

Richmond Agitation-Sedation Scale (RASS) and Riker Sedation-Agitation Scale (SAS) From ICU Delirium, Vanderbilt University. Available at www.ICUdelerium.org. Adapted from Riker RR, Picard JT, Fraser GL. Prospective evaluation of the sedation-agitation scale for adult critically ill patients. Crit Care Med 1999;27(7):1327, and Sessler CN, Gosnell MS, Grap MJ, et al. The Richmond Agitation–Sedation Scale. Am J Resp Crit Care Med 166:1339

Figure 5

(A) Confusion Assessment Method for the ICU (CAM-ICU) (B) Intensive Care Delirium Screening checklist (ICDSC) Copyright E. Wesley, MD, MPH and Vanderbilt University Normal 0; Delirium4–8: Subsyndromal Delirium 1–3 Score your patient over the entire shift. Components don't all need to be present at the same time. Components 1 through 4 cannot be completed when the patient is deeply sedated or comatose (ie. SAS= 1 or 2; RASS = −4 or -5); Components 5 through 8 are based on observations throughout the entire shift. Information from the prior 24 hrs. should be obtained for components 7 and 8. Adapted from Bergeron N, Dubois MJ, Dumont M, Dial S, Skrobik Y. Intensive Care Delirium Screening Checklist: evaluation of a new screening tool. Intensive Care Med. 2001 May;27(5):859–64; Ouimet S, Riker R, Bergeron N, Cossette M, Kavanagh B, Skrobik Y. Subsyndromal delirium in the ICU: evidence for a disease spectrum. Intens CareMed 2007;33:1007–13. Epub 2007 Apr 3; with permission.

Figure 5

(A) Confusion Assessment Method for the ICU (CAM-ICU) (B) Intensive Care Delirium Screening checklist (ICDSC) Copyright E. Wesley, MD, MPH and Vanderbilt University Normal 0; Delirium4–8: Subsyndromal Delirium 1–3 Score your patient over the entire shift. Components don't all need to be present at the same time. Components 1 through 4 cannot be completed when the patient is deeply sedated or comatose (ie. SAS= 1 or 2; RASS = −4 or -5); Components 5 through 8 are based on observations throughout the entire shift. Information from the prior 24 hrs. should be obtained for components 7 and 8. Adapted from Bergeron N, Dubois MJ, Dumont M, Dial S, Skrobik Y. Intensive Care Delirium Screening Checklist: evaluation of a new screening tool. Intensive Care Med. 2001 May;27(5):859–64; Ouimet S, Riker R, Bergeron N, Cossette M, Kavanagh B, Skrobik Y. Subsyndromal delirium in the ICU: evidence for a disease spectrum. Intens CareMed 2007;33:1007–13. Epub 2007 Apr 3; with permission.

Figure 6

Impact of delirium on hospital mortality in critically ill patients. From Salluh JI, Wang H, Schneider EB, et al. Outcome of delirium in critically ill patients: systematic review and meta-analysis. BMJ. 2015 Jun 3;350:h2538. doi: 10.1136/bmj.h2538.

Figure 7

Sample Delirium Protocol. From ICU Delirium, Vanderbilt University. Available at www.ICUdelerium.org.