Running head: THE EFFECT OF THE ABCDE BUNDLE ON THE DURATION OF
MECHANICAL VENTILATION
The Effect of the ABCDE Bundle on the Duration of Mechanical Ventilation
Jordan Furstenau & Melissa Scholtens
Ferris State University
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Running head: THE EFFECT OF THE ABCDE BUNDLE ON THE DURATION OF
MECHANICAL VENTILATION
Abstract
The purpose of this paper is to study the effects of the ABCDE bundle on the duration of
mechanical ventilation. The ABCDE bundle involves a series of protocols that is intended to
decrease delirium, weakness, and length of stay on a ventilator. Evidence is provided through the
critique of several articles that contain studies of the ABCDE bundle. A summary of the most
relevant and best evidence to support the effect of the ABCDE bundle on duration of mechanical
ventilation is provided. The authors also present a critical appraisal of several articles, possible
patient preferences, and determinative factors that could influence the decision of healthcare
professionals to utilize the evidence.
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Running head: THE EFFECT OF THE ABCDE BUNDLE ON THE DURATION OF
MECHANICAL VENTILATION
The Effect of the ABCDE Bundle on the Duration of Mechanical Ventilation
The need for invasive ventilator support in critical care patients is common and costly. In
an international study almost one third of patients in an intensive care unit (ICU) required
intubation and mechanical ventilation (Esteban et al., 2002). The cost of daily ICU care is
increased approximately 2.5 times if mechanical ventilation is required according to Daily cost of
an intensive care unit day: the contribution of mechanical ventilation (Dasta, 2005). In addition
to the monetary cost of mechanical ventilation the detrimental physiological effects of
mechanical ventilation on the patient need to be addressed. Patients requiring mechanical
ventilation are at “Increased risk for delirium and weakness that not only influence a patient’s
ability to survive critical illness, but are associated with poor long-term physical, functional and
cognitive outcomes” (Balas, et al., 2012). In light of the above findings and the absolute need to
provide the patient with the best quality of care and steward healthcare resources and dollars, an
important question becomes how to minimize ventilator length of stay.
Recent research has identified an important group of practices that effectively reduce
delirium and weakness and together these practices are referred to as the ABCDE Bundle. The
A is awakening, BC is breathing coordination, D is delirium monitoring and management, and E
is early mobility, together this group or bundle of care equals the ABCDE bundle. The question
of relevance becomes do ventilated patients that receive care with the awakening, breathing
coordination, delirium monitoring and management, and early mobility (ABCDE) bundle require
fewer ventilator days than ventilated patients who do not receive care with the ABCDE bundle?
A literature review was completed to elucidate the important aspects of the ABCDE bundle, how
this bundle is best implemented, and whether the utilization of this bundle has a significant
impact on ventilator length of stay in intubated ICU patients.
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Running head: THE EFFECT OF THE ABCDE BUNDLE ON THE DURATION OF
MECHANICAL VENTILATION
Patients who require mechanical ventilation not only suffer from an illness that impedes
their ability to maintain their own airway and adequate oxygenation and ventilation, but are also
subjected to the potential ill effects of the many additional medications required to provide
comfort during mechanical ventilation and to decrease distress. Some of the medications
provided to mechanically ventilated patients include sedatives, narcotic analgesics, hypnotics and
amnesiacs. In an effort to provide a more comfortable mechanically ventilated state these classes
of medications are provided but potentially expose the patient to delirium, extended length of
ventilator days and profound muscular weakness (and generalized weakness impairs ventilator
weaning as well as functional mobility). The goal of the ABCDE Bundle is decrease all of these
risks through a collaborative multidisciplinary effort for the better of not only the patient, but the
staff as well.
A Review of Literature
“Critical Care Nurses’ Role in implementing the “ABCDE Bundle” Into Practice” is a
current article published in 2012. The purpose of the study is presented clearly along with the
significance of “strategies to prevent and/or treat ICU acquired delirium and weakness is
urgently needed to improve both outcomes for the ICU patients and the resulting societal
burdens” (Balas et al., 2012). The key areas of investigation within the article include the
following: what are the factors that place a critically ill patient at high risk for developing
delirium and weakness, what are the components of the ABCDE bundle and what is the role of
the critical care nurse in implementation of the ABCDE bundle. The evidence presented within
the article is related to a meta-analysis including clinical trials, randomized controlled trials, a
retrospective study analysis and literature review. The subjects for every category of the
ABCDE bundle were mechanically ventilated intensive care unit patients. The authors of this
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Running head: THE EFFECT OF THE ABCDE BUNDLE ON THE DURATION OF
MECHANICAL VENTILATION
article did not directly conduct the studies, but analyzed the cumulative data from studies that
had already occurred.
Awakening (the A in the bundle) refers to a daily awakening that occurs when the
sedation is interrupted allowing the patient to awaken and follow simple commands and “they
found that daily interruption of sedation, now referred to as spontaneous awakening trials
(SATs), led to a significant decrease in the duration of mechanical ventilation” (Balas et al.,
2012). Breathing Coordination (the BC in the bundle) allows assessment of the patient’s ability
to breathe without the full support of the ventilator to evaluate a patient’s readiness to breathe on
his or her own. A randomized controlled trial found that “patients receiving the wake-up and
breathing coordination intervention spent significantly more days breathing without ventilator
assistance and were discharged from the ICU and hospital earlier” (Balas, et al., 2012). Delirium
monitoring and management (the D in the bundle) is of the utmost importance as delirium is a
significant problem within the ICU and is associated with many unfavorable outcomes including
higher ICU costs, longer ICU length of stay as well as increased ICU mortality (Balas, et al.
2012). Early mobility (the E in the bundle) refers to getting the patients up and moving despite
mechanical ventilation in an effort to reduce muscle atrophy and delirium. “Patients in the
intervention group who were randomly assigned to early exercise and mobility had a
significantly shorter duration of delirium and more ventilator-free days than the control patients”
(Balas, et al., 2012). The evidence points to a common theme: utilization of the protocols within
the ABCDE bundle decrease ventilator days and decreases delirium and weakness.
“Liberation and animation for ventilated ICU patients: the ABCDE bundle for the backend of critical care” by Pandharipande, Banerjee, McGrane & Ely was published for critical care
physicians in 2010 in Critical Care. The purpose is of the article is to evaluate “an evidence-
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Running head: THE EFFECT OF THE ABCDE BUNDLE ON THE DURATION OF
MECHANICAL VENTILATION
based organizational approach referred to as the ABCDE bundle” (Pandharipande et al., 2010).
The focus is on improving back-end care to optimize the outcomes and recovery for patients
(Pandharipande et al., 2010). The article refers to the ABCDE bundle as Awakening and
Breathing Coordination of daily sedation and ventilator removal trials; Choice of sedative or
analgesic exposure; delirium monitoring and management; and early mobility and Exercise.
Studies found that implementing just the first two pieces, the A and BC “yielded a 4-day
reduction in ICU and lengths of stay and an unprecedented 15% reduction in 1-year mortality
(Pandharipande et al., 2010). Delirium monitoring through the utilization of various newly
developed scales such as Confusion Assessment Method or CAM-ICU allows early detection
and intervention. It has been identified that medications given for sedation actually cause and/or
add to delirium. “Benzodiazepines in particular are identified as a modifiable risk factor for
delirium, studies show that using an alternative medication (dexedetomine /Precidex) patients
experienced a 20% or more reduction in rated of delirium while on mechanical ventilation”
(Pandharipande et al., 2010). Early mobility and exercise are the final component of the bundle
and work to decrease weakness. “The mobility groups within the experimental study
experienced roughly a 50% reduction in ICU delirium” (Pandharipande et al., 2010). The
information reveals utilization of the ABCDE bundle combats several adverse effects of
sedation, mechanical ventilation and hospitalization in the ICU. The bundle can be initiated little
potential for adverse effects on the patient.
An article by Stevens, Ely, and Coursins provided evidence to support the effectiveness
of the ABCDE bundle. The authors provide evidence to support that delirium decreases the
overall health of patients and results in a 10% increase in risk of death per day (Stevens et al.,
2012). The ABCDE bundle has the ability to decrease the risk of death through the management
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Running head: THE EFFECT OF THE ABCDE BUNDLE ON THE DURATION OF
MECHANICAL VENTILATION
of delirium and weakness. The ABCDE bundle is a tool that can help get the patients off the
ventilator more quickly. The components of the bundle can be used to help standardize
communication, improve interdisciplinary care, reduce mortality, and potentially improve longterm cognitive and functional outcomes (Stevens et al., 2012). The authors were able to provide
supporting evidence to their claims. One focus on the bundle is to get the patient off sedatives
more quickly in order to reduce the chances for delirium. A result of this action included in the
ABCDE bundle equates to less time on the ventilator. The effects of mechanical ventilation are
devastating to the patient and the ABDCE bundle is geared at decreasing these effects.
“Reducing iatrogenic risks: ICU-delirium and weakness-Crossing the quality chasm” was
published in 2010 in CHEST with is a publication for the American College of Chest Physicians.
The article “advocates for the adoption and implementation of a standard bundle of ICU
measures with great potential to reduce the burden of ICU-acquired delirium and weakness”
(Vasilevskis et al., 2010). Through delivery of the ABCDE bundle patients’ long-term quality of
life and survival are impacted. The article illustrates that patients “experiencing ICU delirium
have a 49% increased risk of remaining in the hospital on any given day compared to those
without delirium” (Vasilevskis et al., 2010). Vasilevskis et al. clearly illuminates that “patients
will wake up, breathe, and exercise if we allow them” (Vasilevskis et al., 2010). This highlights
the ABC and E of the bundle in one concise statement. By limiting sedation and coordinating
with respiratory care the patient will wake up and breathe, add physical therapy and occupational
therapy and the patient gets exercise. Allowing all of these practices to work together decreases
delirium and muscle weakness and contributes to a positive outcome for the patient.
Analysis of the Evidence
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Running head: THE EFFECT OF THE ABCDE BUNDLE ON THE DURATION OF
MECHANICAL VENTILATION
The articles compiled for this evidence-based nursing practice paper were obtained with
specialty search engines. The search engines utilized were PubMed, CINAHL, Medscape, and
Medline. The articles contained Level I, level II and level IV evidence as outlined by the
Hierarchy of Evidence and all of the articles evaluated were published within the last five years.
The journals that published the articles are well known within the medical community and
respected for their contribution to medicine.
The evidence from the articles presented appears clear and concise; putting into practice
the evidence-based practice protocols of the ABCDE bundle will result in less delirium, less
generalized weakness and less time spent on the ventilator. The analysis of the ABCDE bundle
reveals protocol driven sedation holidays to allow for neurological assessment and assessment
for delirium and delirium management, as well as offering an opportunity for the patient to
demonstrate his or her ability to wean from the ventilator. The protocol driven reduction or
elimination of sedation by nursing staff joins with the spontaneous breathing trials (SBTs) or
breathing coordination performed in conjunction with respiratory therapists. SBTs are part of a
respiratory care driven weaning protocol that can lead to a “significantly shortened time to
extubation when compared with physician driven weaning” (Balas et al., 2012). The last piece
of the bundle is early mobility. Early mobility for ventilated patients takes place when the patient
meets certain criteria according to various algorithms and protocols. Nursing in partnership with
physical and occupation therapy assess readiness for mobility and providing the patient meets
criteria immediate therapy would begin. “Early mobilization of ICU patients reduces acute
cognitive and physical dysfunction and early physical therapy has been shown to independently
reduce hospital length of stay up to 3 days” (Vasilevskis et al., 2010). The evidence presented
calls for a change in practice that is evidence-based. This practice change would therefore be
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Running head: THE EFFECT OF THE ABCDE BUNDLE ON THE DURATION OF
MECHANICAL VENTILATION
expected to result in a significant decrease in patient delirium, muscle weakness and length of
time on the ventilator.
Application of the Evidence
The ABCDE bundle requires a collaborative effort from nursing, physicians, respiratory
care and physical and occupational therapists. In order to implement and fully utilize the
practices and protocols represented in the bundle there has to be a multidisciplinary collaboration
as well as a paradigm shift in practice and mind set from “what has always been” and “but that’s
the way we have always done it” perspectives.
In order to implement a new protocol based on the evidence-based practice guidelines
and standards for the ABCDE bundle, a significant amount of education would be needed
starting with physicians. Physicians would need to embrace changes in medication
administration, ordering ventilator weaning protocols, setting goals for sedation titration as well
as sedation holidays and interventions from physical and occupational therapy. Nurses would
need education on the importance of sedation weaning and holidays, how to treat patients
discomfort while sedation is held, standard assessment methods for delirium and methods to
reduce or eliminate delirium. Nurses would have to work in close collaboration with respiratory
care for timing of medication holds to coincide with SBTs and breathing coordination
techniques. Respiratory care would have to have education on the completion of SBTs and daily
weaning protocols to evaluate patient readiness for ventilator weaning or independence.
Respiratory care would also need education in working in collaboration with nursing and
physical therapy (PT) and occupational therapy (OT) to implement early mobility. PT would
need education on the protocols for early mobility in the mechanically ventilated patients and
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Running head: THE EFFECT OF THE ABCDE BUNDLE ON THE DURATION OF
MECHANICAL VENTILATION
would have to work in a joint effort with nursing and respiratory care to provide ambulation of
patients requiring ventilator support.
Barriers to implementation of the ABCDE bundle would be lack of education the
necessary resources to provide the education required to implement the protocol driven bundle.
Lack of willingness to change perspective would be a road block to implementation of the
bundle as well as the financial resources needed to provide the education to change protocol. It
is suggested that “the ABCDE bundle should not depend upon an individual physician’s order
but rather should be structured as a daily part of care with clearly defined safety guidelines”
(Balas et al., 2012). Standardizing the ABCDE bundle as a part of daily care would eliminate the
obstacle of a physician who was unfamiliar with the protocol or just a missed order.
Each individual piece of the ABCDE bundle is an evidence-based practice that is supported by
years of research and clinical studies. Establishment of the bundle as a routine part of daily
patient care is ultimately dependent on the support of and collaboration between all of the
necessary disciplines. “The ABCDE bundle represents just one method of approaching the
organizational changes that need to occur to effect a change of culture that will breed success”
(Pandharipande et al., 2010).
Summary
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Running head: THE EFFECT OF THE ABCDE BUNDLE ON THE DURATION OF
MECHANICAL VENTILATION
References
Balas, M., Vasilevskis, E., Burke, W., Boehm, L., Pun, B., Olsen, K.,…Ely, W. (2012). Critical
care nurses’ role in implementing the “ABCDE Bundle” into practice. Critical Care
Nurse, 32, 35-47. doi:10.4037/ccn2012229
Dasta, J., McLaughlin, T., Mody, S., & Piech, C. (2005). Daily cost of intensive care unit day:
the contribution of mechanical ventilation. Critical Care Medicine, 33(6):1266-1271.
Esteban, A., Anzueto, A., Frutos, F., Alia, I., Brochard, L., Stewart, T., Benito, S.,…Tobin, M.
(2002). Characteristics and outcomes in adult patients receiving mechanical ventilation.
JAMA, 287(3), 345-355. doi:10.1001/jama.287.3.345
Pandharipande, P., Banerjee, A., McGrane, S. & Ely, W. Liberation and animation for ventilated
ICU patients: the ABCDE bundle for the back-end critical care. Critical Care, 14(3),
157. doi:10.1186/cc8999
Stevens, R. D., Ely, E. W., & Coursin, D. B. (2012, June). Sedation and delirium in the ICU.
Critical Connections, 13-14. Retrieved November 13, 2012
Vasilevskis, E., Ely, W., Speroff, T., Pun, B., Boehm, L. & Dittus, R. (2010). Reducing
iatrogenic risks: ICU-acquired delirium and weakness-crossing the quality chasm.
CHEST, 138(5), 1224-1233. doi:10.1378/chest.10-0466
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Running head: THE EFFECT OF THE ABCDE BUNDLE ON THE DURATION OF
MECHANICAL VENTILATION
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