ABCDE and ABCDEF care bundles: A systematic review of the implementation process in intensive care units

Abstract

Background: The ABCDE (Awakening and Breathing Coordination of daily sedation and ventilator removal trials, Delirium monitoring and management, and Early mobility and exercise) and ABCDEF (Assessment, prevent and manage pain, Both spontaneous awakening and spontaneous breathing trials, Choice of analgesia and sedation, assess, prevent and manage Delirium, Early mobility and exercise, Family engagement) care bundles consist of small sets of evidence-based interventions and are part of the science behind Intensive Care Unit (ICU) liberation. This review sought to analyse the process of implementation of ABCDE and ABCDEF care bundles in ICUs, identifying barriers, facilitators and changes in perception and attitudes of healthcare professionals; and to estimate care bundle effectiveness and safety.

Methods: We selected qualitative and quantitative studies addressing the implementation of ABCDE and ABCDEF bundles in the ICU, identified on MEDLINE, Embase, CINAHL, The Cochrane Library, Web of Science, Epistemonikos, PsycINFO, Virtual Health Library and Open Grey, without restriction on language or date of publication, up to June 2018. The outcomes measured were ICU and hospital length of stay; mechanical ventilation time; incidence and prevalence of delirium or coma; level of agitation and sedation; early mobilization; mortality in ICU and hospital; change in perception, attitude or behaviour of the stakeholders; and change in knowledge of health professionals. Two reviewers independently selected the studies, performed data extraction, and assessed risk of bias and methodological quality. A meta-analysis of random effects was performed.

Results: Twenty studies were included, 13 of which had a predominantly qualitative and 7 a quantitative design (31,604 participants). The implementation strategies were categorized according to the taxonomy developed by the Cochrane Effective Practice and Organization of Care Group and eighty strategies were identified. The meta-analysis results showed that implementation of the bundles may reduce length of ICU stay, mechanical ventilation time, delirium, ICU and hospital mortality, and promoted early mobilization in critically-ill patients.

Conclusions: : This study can contribute to the planning and execution of the implementation process of ABCDE and ABCDEF care bundles in ICUs. However, the effectiveness and safety of these bundles need to be corroborated by further studies with greater methodological rigor.

Protocol registration: PROSPERO CRD42019121307.

Figure 1

Study selection process.

Figure 2

Forest plot summarizing the effects of ABCDE and ABCDEF bundles implementation for ICU length of stay outcome, in number of days. ABCDE = Awakening and Breathing Coordination of daily sedation and ventilator removal trials, Delirium monitoring and management, and Early mobility and exercise; ABCDEF = Assessment, prevent and manage pain, Both spontaneous awakening and spontaneous breathing trials, Choice of analgesia and sedation, assess, prevent and manage Delirium, Early mobility and exercise, Family engagement; ICU = intensive care unit.

Figure 3

Forest plot summarizing the effects of ABCDE and ABCDEF bundles implementation for mechanical ventilation time outcome, in number of days. ABCDE = Awakening and Breathing Coordination of daily sedation and ventilator removal trials, Delirium monitoring and management, and Early mobility and exercise; ABCDEF = Assessment, prevent and manage pain, Both spontaneous awakening and spontaneous breathing trials, Choice of analgesia and sedation, assess, prevent and manage Delirium, Early mobility and exercise, Family engagement.

Figure 4

Forest plot summarizing the effects of ABCDE and ABCDEF bundles implementation for delirium outcome, assessed with Confusion Assessment Method in Intensive Care Unit (CAM-ICU) or Intensive Care Delirium Screening Checklist (ICDSC). ABCDE = Awakening and Breathing Coordination of daily sedation and ventilator removal trials, Delirium monitoring and management, and Early mobility and exercise; ABCDEF = Assessment, prevent and manage pain, Both spontaneous awakening and spontaneous breathing trials, Choice of analgesia and sedation, assess, prevent and manage Delirium, Early mobility and exercise, Family engagement.

Figure 5

Forest plot summarizing the effects of ABCDE bundle implementation for coma outcome, in percentage. ABCDE = Awakening and Breathing Coordination of daily sedation and ventilator removal trials, Delirium monitoring and management, and Early mobility and exercise.

Figure 6

Forest plot summarizing the effects of ABCDE bundle implementation for sedation outcome, assessed with the Richmond Agitation-Sedation Scale (RASS). ABCDE = Awakening and Breathing Coordination of daily sedation and ventilator removal trials, Delirium monitoring and management, and Early mobility and exercise.

Figure 7

Forest plot summarizing the effects of ABCDE bundle implementation for early mobilization outcome, in percentage. ABCDE = Awakening and Breathing Coordination of daily sedation and ventilator removal trials, Delirium monitoring and management, and Early mobility and exercise.

Figure 8

Forest plot summarizing the effects of ABCDE bundle implementation for ICU mortality outcome, in percentage. ABCDE = Awakening and Breathing Coordination of daily sedation and ventilator removal trials, Delirium monitoring and management, and Early mobility and exercise; ICU = intensive care unit.

Figure 9

Forest plot summarizing the effects of ABCDE bundle implementation for hospital mortality outcome, in percentage. ABCDE = Awakening and Breathing Coordination of daily sedation and ventilator removal trials, Delirium monitoring and management, and Early mobility and exercise.

Figure 10

Forest plot summarizing the effects of ABCDE bundle implementation for hospital length of stay outcome, in number of days. ABCDE = Awakening and Breathing Coordination of daily sedation and ventilator removal trials, Delirium monitoring and management, and Early mobility and exercise.