ABCDE Bundle Newsletter Article
The 1, 2, 3’s of the ABCDE Bundle
INTRODUCTION
What is the ABCDE Bundle?*
As healthcare clinicians, we are becoming
increasingly aware of the unintended
consequences of the patient care we provide.
To minimize these effects, we must focus on
seeking the evidence that supports our
interventions, which are designed to return
patients to their normal lives.
The ABCDE Bundle is an evidence-based,
organizational approach to the management of
acutely ill patients and includes the following
components:
Over the past several years more and more
evidence has come to light on how to best
manage patients with complex, acute illnesses.
So much information is available on this subject
that articles on intensive care unit practices can
be found in mainstream media, such as the
Wall Street Journal.
D – Delirium Assessment and Management
For patients to move safely through our
complex systems there must be a collaboration
and alignment of people, processes and
technology. Recently, attention has focused on
bundle approaches, which are intended to
serve as guides to aligning all of these factors.
One such approach, the ABCDE Bundle,
consists of multiple, interdependent
components that are designed to:
•
•
•
Improve collaboration among clinical
team members
Standardize care processes
Break the cycle of suboptimal sedation
practices such as over- and undersedation
ABC – Awakening and Breathing Trial
Coordination
E – Early Exercise and Progressive Mobility
*Note: Some institutions have chosen to
separate out the “C” and make it stand for
“Choice of Sedation,” allowing it to
represent the Sedation Protocol.
While not every patient will require every
component of the bundle (based on their acuity
or treatment plan), there should be an
assessment as to which components may apply
to individual patients.
WHAT CAN WE DO?
Each piece of the ABCDE Bundle is supported
by independent study and evidence-based
practice. The goal of the bundle approach is to
promote collaboration among members of a
multidisciplinary team, which encourages
ongoing communication, helps implement
standardized care processes and breaks the
cycle of suboptimal sedation practices. Each
component of the bundle includes assessments
and interventions designed to prevent or
minimize the unintended consequences of our
patient care.
ABCDE BUNDLE COMPONENTS
Awake and Breathing Trial Coordination
The ABC component of the bundle is a
collaborative approach to administering the
appropriate type and amount of sedation, safely
allowing the patient to wake up daily and safely
evaluating the patient’s ability to breathe
independent of the ventilator. This requires
collaboration between physicians, nurses,
respiratory therapists and pharmacists. Even
non-ventilated patients receiving sedation
will benefit from some of the elements of
this bundle.
Delirium Assessment and Management
The D component of the bundle is concerned
with assessing for and managing delirium. What
used to be thought of as “ICU psychosis” is now
known to be delirium. This element involves a
process to monitor for the presence of delirium
on a daily basis. First, the presence of pain and
agitation must be addressed. Valid, reliable and
quick assessment tools are necessary. Once
delirium is detected, managing it is vital. While
no single drug is the “magic bullet” for
minimizing the effects of delirium, research
continues to identify the most effective
management strategies – pharmacologic and
non-pharmacologic. All patients should be
assessed for the presence of delirium.
Early Exercise and Progressive Mobility
The final component of the bundle involves
getting patients moving earlier. This
incorporates everything from passive and active
range of motion to ambulation. As with the
spontaneous awakening and spontaneous
breathing trials (SATs and SBTs), a safety
screening is performed to determine the
patient’s readiness for increased activity.
Whether the patient is in the critical care unit or
on a progressive care unit, safely mobilizing
patients will improve their outcomes. All
patients should be evaluated and assessed
for progressive mobility needs.
IMPLEMENTATION
Tools and algorithms are available for each of
the bundle components. Through the
collaboration of a multidisciplinary team, care
process can be standardized and patients will
experience both fewer unintended
consequences and improved outcomes.
Tools
The ABCDE bundle contains easy-to-use
algorithms for SATs, SBTs, delirium
assessment and management, and ICU
mobility. All of the tools can be customized to
the specific needs of your institution.
Documentation and communication are vital to
understanding how a patient is fairing in the
ICU environment on a day-to-day basis,
evaluating patient readiness to advance and
assisting the team in making decisions about
how best to manage the patient. Utilizing a daily
goal sheet for each patient may help facilitate
communication between multidisciplinary team
members.
Additional Resources
AACN Practice Alert – Delirium Assessment
and Management
http://www.aacn.org/WD/practice/content/practi
cealerts/delirium-practice-alert.content
ICU Delirium: www.icudelirium.org
Institute for Healthcare Improvement
http://www.ihi.org/explore/Bundles/Pages/defaul
t.aspx