Helping Critically Ill Patients and Families Thrive through an ABCDEF Approach

2015 - 4 August – Post-Intensive Care Syndrome
Michele C. Balas, PhD, RN, APRN-NP, CCRN, DC; Mary Ann Barnes-Daly, RN, BSN, CCRN, DC; Diane Byrum, MSN, RN, CCNS, CCRN, FCCM; Brenda T. Pun, RN, MSN; E. Wesley Ely, MD, MPH, FCCM
Five experts review the implementation of the ABCDEF Bundle as it relates to PICS.


Post-intensive care syndrome (PICS) is a devastating and often life-altering condition experienced by an increasing number of critically ill patients and their family members. As described by a 2010 Society of Critical Care Medicine (SCCM) task force,(1) PICS is a complex syndrome that encompasses new or worsening impairments in physical, cognitive, or mental health status arising after critical illness and persisting beyond acute care hospitalization. While the etiology of PICS is complex and believed to be multifactorial, evidence generated during the past several decades suggests that there are a number of important, potentially modifiable risk factors that may be reduced through early and reliable adoption of interprofessional, evidence-based intensive care unit (ICU) interventions. As outlined in SCCM’s Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit,(2) some of these safe and effective interventions include: maintaining light levels of sedation, using nonbenzodiazepine-based sedatives, administering valid and reliable pain, agitation, and delirium (PAD) monitoring tools, and performing early mobilization whenever clinically feasible. The Choosing Wisely® initiative, aimed at helping patients choose care that is supported by evidence, free from harm and truly necessary, has also helped generate a national dialogue on the potential long-term hazards of some routinely applied ICU practices. For example, one of the first Choosing Wisely® recommendations related to critical care is, “Don’t deeply sedate mechanically ventilated patients without a specific indication and without daily attempts to lighten sedation.” Additional information about this recommendation is available at

One strategy for incorporating the 2013 PAD guideline recommendations into everyday care, and thus potentially reducing the incidence of PICS, is the newly modified ABCDEF bundle, comprising the following components: Assess, prevent, and manage pain; ssess, prevent, and manage pain; Both spontaneous awakening trials and spontaneous breathing trials; Choice of analgesia and sedation; hoice of analgesia and sedation; Delirium: assess, prevent, and manage; Early mobility and exercise; and arly mobility and exercise; and Family engagement and empowerment. [See Figure 1.(3-5)] The individual components of the ABCDEF bundle ( are evidence based and were recently shown to be safe and effective when incorporated into everyday care.(6) They are recommended by a number of national patient safety and quality organizations, such as the Institute for Healthcare Improvement. One of the strengths of the ABCDEF bundle is that the individual interventions are straightforward and clearly defined (e.g., a suggested safety screen and pass/fail criteria). The bundle is also flexible, enabling each institution to tweak the interventions to meet the unique needs of its patients and its own culture. Above all, the bundle highlights the importance of assessing, preventing and managing pain while engaging and empowering patients’ family members to advocate for successful ABCDEF delivery.

Significant ABCDEF bundle implementation challenges remain. One possible reason for the delay in implementation is that some institutions use some, but not all, of the interventions, expecting dramatic improvements in patient outcomes. Interventions comprising the ABCDEF bundle are interrelated and interdependent. For example, a patient who is deeply sedated cannot be mobilized, and medication cannot be titrated to a light level of sedation without the sedation level first being reliably assessed. Additionally, implementation of the ABCDEF bundle requires multiple members of the healthcare team to collaborate and coordinate care activities. The ABCDEF bundle is a tool. Effective implementation requires acknowledgment of the interconnectedness of the people, processes, and evidence(5) involved. [See Figure 2.(5)] Unfortunately, until recently, more emphasis was placed on the science behind the bundle and less on the importance of these human and system factors.

SCCM has launched an ICU Liberation collaborative related to implementing the PAD guidelines via application of the ABCDEF bundle. Through the generous support of the Gordon and Betty Moore Foundation, 76 U.S. hospital ICUs in three different regions will work with a team of leading national and regional experts to:

• Optimize pain control plus reduce sedative exposure and time on mechanical ventilation
• Improve time patients are free of delirium and coma
• Improve a team approach to early mobilization
• Engage families to participate in the care and healing of their loved ones
• Validate compliance and improvement through use of an online data collection tool
• Enhance teamwork through implementation of evidence-based care
• Engage with leading experts who have demonstrated improved patient outcomes through the ABCDEF bundle
• Create partnerships with other institutions doing the same improvement work across the United States

This multi-institutional partnership will substantially advance understanding of the potential patient- and family-centered benefits of reliable ABCDEF bundle adoption. The collaborative will seek to better understand the organizational, unit-level, and profession-specific factors associated with bundle compliance and facilitators and barriers to optimal team performance, communication, and a healthy work environment.

While the effect of reliable ABCDEF bundle adoption on the incidence and outcomes of PICS has yet to be fully studied, intuitively it is an extremely promising approach. For example, effectively managing critically ill patients’ pain and avoiding oversedation may lead to increased cognitive engagement and improved physical activity, thus reducing the risk for ICU-acquired weakness and the many mental health problems associated with PICS. Similarly, effectively engaging and empowering family members to be active partners in patient care early in the course of a serious illness may lead to improved self-care and early recognition and treatment of patients’ personal challenges. Collectively, the evidence-based interventions that make up the ABCDEF bundle may substantially reduce the incidence of PICS, allowing critically ill patients and their families to thrive after a serious illness. For more information about the ABCDEF bundle and ICU Liberation activities, please visit and



1. Needham DM, Davidson J, Cohen H, et al. Improving long-term outcomes after discharge from intensive care unit: report from a stakeholders' conference. Crit Care Med. 2012 Feb;40(2):502-509.
2. Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013 Jan;41(1):263-306.
3. Morandi A, Brummel NE, Ely EW. Sedation, delirium and mechanical ventilation: the 'ABCDE' approach. 3. Morandi A, Brummel NE, Ely EW. Sedation, delirium and mechanical ventilation: the 'ABCDE' approach. Curr Opin Crit Care. 2011 Feb;17(1):43-49.
4. Pandharipande P, Banerjee A, McGrane S, Ely EW. Liberation and animation for ventilated ICU patients: the ABCDE bundle for the back-end of critical care. Crit Care. 2010;14(3):157.
5. Vasilevskis EE, Ely EW, Speroff T, Pun BT, Boehm L, Dittus RS. Reducing iatrogenic risks: ICU-acquired delirium and weakness—crossing the quality chasm. Chest. 2010 Nov;138(5):1224-1233.
6. Balas MC, Vasilevskis EE, Olsen KM, et al. Effectiveness and safety of the awakening breathing coordination, delirium monitoring/management, and early exercise/mobility bundle. Crit Care Med. 2014 May;42(5):1024-1036.