Creating a Culture of an Awake and Walking Intensive Care Unit: In-Hospital Strategies to Mitigate Post-Intensive Care Syndrome

Kali Dayton¹, Heidi Lindroth², Heidi J Engel³, Mikita Fuchita⁴, Phillip Gonzalez⁵, Peter Nydahl⁶, Joanna L Stollings⁷, Leanne M Boehm⁸

Affiliations

¹ Dayton ICU Consulting, 13816 East 41st Avenue, Spokane, Washington 99206, USA.
² Department of Nursing, Mayo Clinic, 200 First Street SW, Rochester, MN 55902, USA; Center for Innovation and Implementation Science and the Center for Aging Research, Regenstrief Institute, School of Medicine, Indiana University, 1101 West 10th Street, Indianapolis, IN 46202, USA.
³ University of California San Francisco Medical Center (UCSF), 400 Parnassus Avenue A68, San Francisco, CA 94143, USA. Electronic address: https://twitter.com/HeidiEngel4.
⁴ Department of Anesthesiology, Division of Critical Care, University of Colorado Anschutz Medical Campus, 12401 East 17th Avenue, 7th Floor, Aurora, CO 80045, USA. Electronic address: https://twitter.com/mikitafuchita.
⁵ VitalGo Systems, 3315 Commerce Parkway, Mirimar, FL 33025, USA.
⁶ Nursing Research, University Hospital of Schleswig-Holstein, Arnold-Heller-Str 3, 24105 Kiel, Germany; Institute of Nursing Science and Development, Paracelsus Medical University, Strubergasse 21, 5020 Salzburg, Austria.
⁷ Department of Pharmaceutical Services, Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN 37232, USA; Vanderbilt University School of Nursing, 461 21st Avenue South, 419 Godchaux Hall, Nashville, TN 37240, USA.
⁸ Vanderbilt University School of Nursing, 461 21st Avenue South, 419 Godchaux Hall, Nashville, TN 37240, USA; Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center at Vanderbilt, Nashville, TN, USA. Electronic address: leanne.boehm@vanderbilt.edu.

PMID: 39547720
PMCID: PMC11809611
DOI: 10.1016/j.ccc.2024.08.002

Review

Creating a Culture of an Awake and Walking Intensive Care Unit: In-Hospital Strategies to Mitigate Post-Intensive Care Syndrome

Kali Dayton et al. Crit Care Clin. 2025 Jan.

. 2025 Jan;41(1):121-140.

doi: 10.1016/j.ccc.2024.08.002. Epub 2024 Sep 16.

Authors

Kali Dayton¹, Heidi Lindroth², Heidi J Engel³, Mikita Fuchita⁴, Phillip Gonzalez⁵, Peter Nydahl⁶, Joanna L Stollings⁷, Leanne M Boehm⁸

Affiliations

¹ Dayton ICU Consulting, 13816 East 41st Avenue, Spokane, Washington 99206, USA.
² Department of Nursing, Mayo Clinic, 200 First Street SW, Rochester, MN 55902, USA; Center for Innovation and Implementation Science and the Center for Aging Research, Regenstrief Institute, School of Medicine, Indiana University, 1101 West 10th Street, Indianapolis, IN 46202, USA.
³ University of California San Francisco Medical Center (UCSF), 400 Parnassus Avenue A68, San Francisco, CA 94143, USA. Electronic address: https://twitter.com/HeidiEngel4.
⁴ Department of Anesthesiology, Division of Critical Care, University of Colorado Anschutz Medical Campus, 12401 East 17th Avenue, 7th Floor, Aurora, CO 80045, USA. Electronic address: https://twitter.com/mikitafuchita.
⁵ VitalGo Systems, 3315 Commerce Parkway, Mirimar, FL 33025, USA.
⁶ Nursing Research, University Hospital of Schleswig-Holstein, Arnold-Heller-Str 3, 24105 Kiel, Germany; Institute of Nursing Science and Development, Paracelsus Medical University, Strubergasse 21, 5020 Salzburg, Austria.
⁷ Department of Pharmaceutical Services, Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN 37232, USA; Vanderbilt University School of Nursing, 461 21st Avenue South, 419 Godchaux Hall, Nashville, TN 37240, USA.
⁸ Vanderbilt University School of Nursing, 461 21st Avenue South, 419 Godchaux Hall, Nashville, TN 37240, USA; Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center at Vanderbilt, Nashville, TN, USA. Electronic address: leanne.boehm@vanderbilt.edu.

PMID: 39547720
PMCID: PMC11809611
DOI: 10.1016/j.ccc.2024.08.002

Abstract

The ABCDEF bundle and Awake and Walking intensive care unit (ICU) approach aim to prevent the long-term consequences of critical illness (ie, post-intensive care syndrome) by promoting patient wakefulness, cognition, and mobility. Humanizing the ICU experience is the key, preserving patients' function and autonomy. Successful implementation requires cultivating an ICU culture focused on avoiding sedatives and initiating prompt mobilization, addressing organizational barriers through tailored strategies. Overall, these patient-centered, mobility-focused models offer a holistic solution to the complex challenge of preventing post-intensive care syndrome and supporting critical illness survivors.

Keywords: ABCDEF; Awake and walking; Bundle; Critical care; Intensive care unit; Post-intensive care syndrome.

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Conflict of interest statement

Disclosures K. Dayton is the owner of Dayton ICU Consulting. H. Lindroth received grant funding from National Institutes of Health, United States NIA (1K23AG076662-02). H.J. Engel served as consultant for Arjo-Huntleigh and served as speaker for American Physical Therapy Association. M. Fuchita is supported by a mentored research training grant from the National Institute of Health, National Institute of General Medical Sciences, United States (T32GM135169). P. Gonzalez is a salaried (non-sales/commission based) clinical educator and product specialist for VitalGo Systems. L.M. Boehm received grant funding from National Institutes of HealthNIA, United States (R01AG077644 and R42AG080891).

Figures

**Figure 1.**
The Timeline of Evidence Supporting the Awake and Walking Intensive Care Unit

**Figure 2.**
The Interlinked Nature and Continuum of Critical Care and Its Effect on Outcomes

**Figure 3.**
Implementation Strategies and Adaptations to Enhance Adoption of the Awake and Walking Intensive Care Unit The problem and descriptions are informed by the Organizational Theory of Innovation Implementation Effectiveness. The suggested implementation strategy categories are informed by the Expert Recommendations for Implementing Change (ERIC) implementation strategy compilation.

See this image and copyright information in PMC

References

1. Dayton K, Hudson M, Lindroth H. Stopping Delirium Using the Awake-and-Walking Intensive Care Unit Approach: True Mastery of Critical Thinking and the ABCDEF Bundle. AACN Advanced Critical Care. 2023;34(4):359–366. doi: 10.4037/aacnacc2023159. - DOI - PMC - PubMed
1. Pun BT, Balas MC, Barnes-Daly MA, et al. Caring for critically ill patients with the ABCDEF bundle: results of the ICU liberation collaborative in over 15,000 adults. Critical Care Medicine. 2019;47(1):3–14. doi: 10.1097/CCM.0000000000003482. - DOI - PMC - PubMed
1. Investigators TS, Group tACT. Early active mobilization during mechanical ventilation in the ICU. New England Journal of Medicine. 2022;387(19):1747–1758. doi:10.1056/NEJMoa2209083. - DOI - PubMed
1. Morris PE, Goad A, Thompson C, et al. Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Clinical Trial Research Support, N.I.H., Extramural Research Support, Non-U.S. Gov’t. Critical Care Medicine. Aug 2008;36(8):2238–43. doi:10.1097/CCM.0b013e318180b90e. - DOI - PubMed
1. Wunsch H, Angus DC, Harrison DA, et al. Variation in critical care services across North America and Western Europe. Critical Care Medicine. 2008;36(10):2787–e8. doi: 10.1097/CCM.0b013e318186aec8. - DOI - PubMed

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Creating a Culture of an Awake and Walking Intensive Care Unit: In-Hospital Strategies to Mitigate Post-Intensive Care Syndrome

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Creating a Culture of an Awake and Walking Intensive Care Unit: In-Hospital Strategies to Mitigate Post-Intensive Care Syndrome

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