The D component of the ABCDEF Bundle refers to assessing, preventing and managing delirium. 
Delirium is experienced by 50%–80% of mechanically ventilated patients and 20%–50% of patients with illness of lower severity, resulting in prolonged hospitalization, increased mortality and increased cost. Long-term effects on the patient include increased risk of mortality and long-term cognitive impairment. 
 
Implementing the D component of the ABCDEF bundle  
 
Search D Element Resources
 
PAD Delirium Assessment Recommendations
Routinely monitor for delirium in all adult ICU patients.
Use either:
  • Confusion Assessment Method for the ICU (CAM-ICU)
  • Intensive Care Delirium Screening Checklist (ICDSC)
Tools for Delirium Assessment
The Confusion Assessment Method for the ICU (CAM-ICU) and the Intensive Care Delirium Screening Checklist (ICDSC) are the most valid and reliable delirium monitoring tools for adult ICU patients.

CAM-ICU Assessment Tool
CAM-ICU Flowsheet
CAM-ICU Training Manual (Frequently Asked Questions for Putting the CAM-ICU into Practice, pages 16-20)
Intensive Care Delirium Screening Checklist (ICDSC)

Delirium is identified by the following key features:

  • Disturbance in attention and awareness
  • Disturbance in cognition (e.g., memory, disorientation, language, and perception)
  • Development over a short period of time and tendency to fluctuate during the day
  • Disturbance not better explained by a preexisting, established or evolving neurocognitive disorder, and not occurring in the context of a severely reduced level of arousal such as coma
  • Evidence from patient’s history, physical examination and/or laboratory results that the disturbance is caused by a medical condition, substance intoxication or withdrawal, or medication/toxin side effect
Associated but nondiagnostic symptoms of ICU delirium include:
  • Hallucinations and delusions
  • Abnormal psychometric activity (e.g., agitation or lethargy)
  • Emotional disturbances (e.g., fear, anger, depression or apathy)
  • Sleep disturbances
Drugs have the potential for contributing to delirium. The ABCDEF bundle suggests the following approach to delirium management:
  • Stop (consider sedatives, review medications and plan to reduce drug exposure)
  • THINK (Toxic situations, Hypoxemia, Infection/nosocomial sepsis, Immobilization, Nonpharmacologic interventions, K+ or other electrolyte disturbances)
  • Medicate (guideline suggests nonbenzodiazepine sedatives)

Integration of the pain, agitation and delirium (PAD) guidelines and/or the ABCDEF bundle, along with specific delirium prevention strategies leads to a statistically lower mortality and shorter ICU length of stay, along with a static delirium incidence.

Implementing Delirium Screening in the ICU: Secrets to Success
Citation: Crit Care Med. 2013 Sep;41(9):2196-208
Population: Adult
Bundle: D Element
View Reference
Intensive Care Delirium Screening Checklist: evaluation of a new screening tool
Citation: Intensive Care Med. 2001 May;27(5):859-64
Population: Adult
Bundle: D Element
View Reference
A reorientation strategy for reducing delirium in the critically ill: result of an interventional study
Citation: Minerva Anestesiol. 2012 Sep;78(9):1026-33
Population: Adult
Bundle: D Element
View Reference
Delirium in an intensive care unit: a study of risk factors
Citation: Intensive Care Med. 2001 Aug;27(8):1297-304
Population: Adult
Bundle: D Element
View Reference
The impact of delirium in the intensive care unit on hospital length of stay
Citation: Intensive Care Med. 2001 Dec;27(12):1892-900
Population: Adult
Bundle: D Element
View Reference
Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit
Citation: JAMA. 2001 Dec 5;286(21):2703-10
Population: Adult
Bundle: D Element
View Reference
The confusion assessment method for the intensive care unit (CAM-ICU) and intensive care delirium screening checklist (ICDSC) for the diagnosis of delirium: a systematic review and meta-analysis of clinical studies
Citation: Crit Care. 2012 Jul 3;16(4):R115
Population: Adult
Bundle: D Element
View Reference
The effect of a quality improvement intervention on perceived sleep quality and cognition in a medical ICU
Citation: Crit Care Med. 2013 Mar;41(3):800-9
Population: Adult
Bundle: D Element
View Reference
Days of delirium are associated with 1-year mortality in an older intensive care unit population
Citation: Am J Respir Crit Care Med. 2009 Dec 1;180(11):1092-7
Population: Adult
Bundle: D Element
View Reference
Delirium duration and mortality in lightly sedated, mechanically ventilated intensive care patients
Citation: Crit Care Med. 2010 Dec;38(12):2311-8
Population: Adult
Bundle: D Element
View Reference
Implementing delirium screening in the ICU: secrets to success
Citation: Crit Care Med. 2013 Sep;41(9):2196-208
Population: Pediatrics
Bundle: D Element
View Reference
Pediatric delirium: monitoring and management in the pediatric intensive care unit.
Citation: Pediatr Clin North Am. 2013 Jun;60(3):741-60
Population: Adult
Bundle: D Element
View Reference
Pediatric delirium and associated risk factors: a single-center prospective observational study
Citation: Pediatr Crit Care Med. 2015 May;16(4):303-309.
Population: Pediatrics
Bundle: D Element
View Reference
Diagnosing delirium in critically ill children: Validity and reliability of the Pediatric Confusion Assessment Method for the Intensive Care Unit
Citation: Crit Care Med. 2011 Jan;39(1):150-7
Population: Pediatrics
Bundle: D Element
View Reference
Cornell Assessment of Pediatric Delirium: a valid, rapid, observational tool for screening delirium in the PICU
Citation: Crit Care Med. 2014 Mar;42(3):656-63
Population: Pediatrics
Bundle: D Element
View Reference
https://www.ncbi.nlm.nih.gov/pubmed/22407142
Citation: Intensive Care Med. 2012 Jun;38(6):1025-31.
Population: Pediatrics
Bundle: D Element
View Reference
Pediatric delirium: evaluating the gold standard
Citation: Palliat Support Care. 2015 Jun;13(3):513-6
Population: Pediatrics
Bundle: D Element
View Reference