Juliana Barr, MD, FCCM
Six million adults are admitted annually to intensive care units (ICUs) in the United States; ICU admissions account for 20% of all acute care admissions. ICU costs make up over 4% of national healthcare expenditures, and they double every 10 years.1 Preventable harms contribute significantly to ICU morbidity, mortality, and costs. Medical errors and deaths due to preventable harms are more common in the ICU because of higher patient acuity and complexity of care. Some of the most common preventable harms that ICU patients experience are delirium, hospital-acquired weakness, device-related infections, deep vein thromboses, and pressure ulcers. One in five ICU patients are harmed by adverse events, with nearly half of these events being preventable. The aggregated costs of adverse events in ICU patients is estimated to be between $5 billion and $7 billion annually.2,3 Increasing the value of ICU care by increasing the quality, safety, and efficiency of care delivered should be a greater priority for every hospital because ICU care is expensive and inconsistently delivers evidence-based care to our sickest patients. We will describe how implementing the Society of Critical Care Medicine’s (SCCM) evidence-based ABCDEF bundle can significantly improve the value, quality, and safety of care delivered to patients in your ICUs.
Pain, agitation, and delirium (PAD) occur frequently but are often poorly managed in critically ill patients, leading to longer ICU and hospital lengths of stay, higher mortality rates, a higher incidence of long-term physical and cognitive dysfunction, and higher costs of care for these patients.4 Mechanically ventilated ICU patients in particular often receive multiple sedatives, opioids, and antipsychotics to control PAD. This combination often results in a vicious cycle of deep sedation and prolonged mechanical ventilation. Historically, keeping our sickest ICU patients in a drug-induced coma until they got better was the standard of care. But we now know that the combination of deep sedation and prolonged mechanical ventilation can lead to ICU-acquired weakness, delirium, cognitive dysfunction, and secondary complications, such as hospital-acquired infections, deep vein thromboses, and pressure ulcers. These in turn lead to longer ICU and hospital lengths of stay, higher mortality rates, and higher healthcare costs.
Patients who survive their ICU stay often have devastating and irreversible consequences of deep sedation and prolonged mechanical ventilation and are unable to return to their previous level of physical and cognitive functioning. ICU survivors also have higher incidences of chronic pain, depression, anxiety, posttraumatic stress disorder, and lower quality-of-life scores. These problems are collectively referred to as post-intensive care syndrome (PICS).5 PICS can linger in patients for months or even years after ICU discharge, and it places a significant burden on patients and their families. Most patients with PICS are unable to live independently or return to their previous level of functioning, are more likely to be discharged from the hospital to a skilled nursing facility or rehabilitation center, and have higher hospital read mission rates and mortality rates within one year after discharge.5–9 PICS can occur in ICU patients of all ages; it is not limited to elderly patients.
In 2013, SCCM published Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit.4 These guidelines take a more multiprofessional, integrated, and patient-centered approach to managing PAD in critically ill adults, and integrate PAD management with ventilator weaning efforts and early patient mobilization. This integration enables ICU patients to actively participate in their care, wean from mechanical ventilation and mobilize sooner, and hastens their recovery. In 2014, SCCM, with support from the Gordon and Betty Moore Foundation, launched the ICU Liberation Campaign to promote widespread adoption of these guideline recommendations. As part of this campaign, the ABCDEF bundle was created to help translate the guideline recommendations into clinical practice (Figure 1).10
The objectives of the ABCDEF bundle are to optimize pain management, avoid deep sedation, reduce delirium prevalence using primarily nonpharmacologic therapies, shorten the duration of mechanical ventilation, avoid ICU-acquired weakness, and increase ICU patient and family involvement, all in order to achieve significant, synergistic improvements in ICU patient outcomes and reductions in healthcare costs. Bundling these evidence-based practices together helps to standardize care processes, reduce practice variation, and improve ICU team communication, and ensures that all bundle elements are applied appropriately and consistently to all patients. Implementation of the bundle is associated with significant improvements in ICU patient outcomes, including reducing the duration of mechanical ventilation and the prevalence of delirium and coma, increasing patient mobility, and reducing ICU mortality, even with only partial bundle implementation.11,12 These outcomes are similar to the observed improvements in ICU outcomes following bundle implementation by the 77 U.S. hospitals who participated in SCCM’s ICU Liberation collaborative.
The ABCDEF bundle differs significantly from other evidence-based ICU bundles, such as those for sepsis, catheter-associated urinary tract infections, central line-associated bloodstream infections, and ventilatorassociated events. These bundles apply only to subsets of ICU patients, whereas the ABCDEF bundle applies to every ICU patient, every day. The ABCDEF bundle requires a paradigm shift in the care priorities for all ICU patients; instead of waiting for patients to get better, the bundle helps ICU patients get better faster. Perhaps most importantly, the bundle requires a multiprofessional, collaborative, and team-based approach to patient care, to ensure effective communication and care coordination among all clinicians. This approach often requires a transformational change in how care is delivered in the ICU. Organizational characteristics of high-performing ICUs that have been shown to facilitate bundle implementation and sustainability include high-intensity ICU physician staffing; adequate ICU nurse staffing; daily multiprofessional ICU team rounds; use of daily ICU goals sheets, checklists, and protocols that include bundle elements; incorporation of bundle data into the electronic health record (EHR); a collaborative work environment; a culture of safety in the ICU; and strong ICU and hospital leadership support for the bundle (Figure 2).13–15
ICU physician support for the bundle is crucial to successful bundle adoption. Appropriate delivery of bundle elements to all ICU patients at the right time is an interdependent, complex, and dynamic process that requires the careful coordination and collaboration of providers across disciplines. To facilitate this process, ICU physicians must adopt the humble mindset of a servant leader who is responsible for creating an ICU team environment that will make process leadership (determination of how the bundle elements are best performed for each patient) easier for frontline ICU staff to exercise.16 The servant leader who places a high priority on the bundle also helps foster an atmosphere of collaboration among ICU staff, with an emphasis on patient safety. This collaboration helps other members of the ICU team identify novel solutions to commonly encountered problems (e.g., coordination of spontaneous awakening and breathing trials and early mobility efforts by ICU nurses, respiratory therapists, and physical therapists), which improves the efficiency and timeliness of patient care.
These improvements are best achieved through daily multiprofessional ICU team rounds conducted at the patient’s bedside.13 The use of ICU goals sheets, checklists, and protocols that include bundle elements helps create standard procedures for delivery of the bundle elements; these standard procedures reduce provider practice variation and increase the efficiency of patient care. Including ICU patients and their family members in discussions on ICU team rounds helps engage them directly in decision-making, goal-setting, and care processes, and makes the patient’s goals of care a top priority for other team members. Finally, incorporating the bundle elements into the EHR helps to ensure that all bundle elements are addressed for every ICU patient, every day, and that bundle work flows are standardized. Extraction of bundle compliance, performance, and outcome reports from the EHR help translate bundle evidence into clinical practice and reduce ICU clinician practice variation. Incorporating the bundle elements into the EHR requires strong support from the hospital IT staff.
This ICU organizational transformation can occur only with strong support and ongoing engagement by hospital leadership. This requires a sustained, hands-on approach by a hospital officer in the form of executive sponsorship, whereby the officer supports and mentors (but does not lead) the ICU’s bundle implementation team.17 An executive sponsor can help to ensure that the bundle implementation team has sufficient resources (e.g., staff, money, and equipment) to guarantee its success, that bundle implementation efforts are in alignment with the hospital’s core values and strategic plan and will provide an adequate return on investment, and can help spread the bundle throughout the organization.
The value proposition of the ABCDEF bundle is that it helps hospitals achieve the Institute for Healthcare Improvement’s Triple Aim—improved ICU patient outcomes, increased patient and family engagement and satisfaction, and lower costs of care.18 The bundle also helps hospitals transition from volume-based to valuebased ICU care, bringing hospitals and providers into better alignment in providing high-quality ICU care at a lower cost. Finally, the bundle can help to positively transform the practice of critical care medicine, with the goal of returning patients to their previous lives and thriving, rather than just surviving. It’s about restoring the dignity and personhood of our sickest patients.
- Society of Critical Care Medicine. Critical care statistics. Mt. Prospect, IL: Society of Critical Care Medicine. https://www.sccm.org/Communications/Critical-Care-Statistics. Accessed July 9, 2018.
- Rothschild JM, Landrigan CP, Cronin JW, et al. The Critical Care Safety Study: The incidence and nature of adverse events and serious medical errors in intensive care. Crit Care Med. 2005 Aug;33(8):1694-1700.
- Kaushal R, Bates DW, Franz C, Soukup JR, Rothschild JM. Cost of adverse events in intensive care units. Crit Care Med. 2007 Nov;35(11):2479-2483.
- Barr J, Fraser GL, Puntillo K, et al; American College of Critical Care Medicine. 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.
- 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.
- Marra A, Pandaripande PP, Girard TD, et al. Cooccurrence of post-intensive care syndrome problems among 406 survivors of critical illness. Crit Care Med. 2018 May 21. [Epub ahead of print].
- Elliott D, Davidson JE, Harvey MA, et al. Crit Care Med. 2014 Dec; 42(12):2518-2526.
- Harvey MA, Davidson JE. Postintensive care syndrome: right care, right now . . . and later. Crit Care Med. 2016 Feb;44(2):381-385.
- Davidson JE, Harvey MA. Patient and family post-intensive care syndrome. AACN Adv Crit Care. 2016 April-June;27(2):184-186.
- ICU Liberation. ABCDEF bundle. http://www.iculiberation.org/Bundles/Pages/default.aspx. Mt. Prospect, IL: Society of Critical Care Medicine. Accessed June 12, 2018.
- Balas MC, Vasilevskis EE, Olsen KM, et al. Effectiveness and safety of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle. Crit Care Med. 2014 May;42(5):1024-1036.
- Barnes-Daly MA, Phillips G, Ely EW. Improving hospital survival and reducing brain dysfunction at seven California community hospitals: implementing PAD guidelines via the ABCDEF bundle in 6,064 patients. Crit Care Med. 2017 Feb;45(2):171-178.
- Donovan AL, Aldrich JM, Gross AK, et al; University of California San Francisco Critical Care Innovations Group. Interprofessional care and teamwork in the ICU. Crit Care Med 2018 Jun;46(6):980-990.
- Balas MC, Burke WJ, Gannon D, et al. Implementing the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle into everyday care: opportunities, challenges, and lessons learned for implementing the ICU pain, agitation, and delirium guidelines. Crit Care Med 2013 Sep;41(9 Suppl 1):S116-S127.
- Costa DK, Barg FK, Asch DA, Kahn JM. Facilitators of an interprofessional approach to care in medical and mixed medical/surgical ICUs” a multicenter qualitative study. Res Nurs Health. 2014 Aug;37(4):326-335.
- Harvard Business Review. Want to be a more supportive leader? Here’s how. June 25, 2018. Boston, MA: Harvard Business School Publishing Corporation. https://www.physicianleaders.org/news/want-more-supportive-leader-heres-how. Accessed June 27, 2018.
- Kambil A. Four types of executive sponsorship to catalyze change. October 11, 2017. New York, NY: Deloitte Insights. https://www2.deloitte.com/insights/us/en/focus/executive-transitions/four-types-of-executive-sponsorship-to-catalyze-change.html. Accessed June 27, 2018.
- Institute for Healthcare Improvement. The IHI Triple Aim. Boston, MA: Institute for Healthcare Improvement; 2018. http://www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx. Accessed July 24, 2018.