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Worldwide Survey of the “Assessing Pain, Both Spontaneous Awakening and Breathing Trials, Choice of Drugs, Delirium Monitoring/Management, Early Exercise/Mobility, and Family Empowerment” (ABCDEF) Bundle

Morandi, Alessandro MD, MPH1,2; Piva, Simone MD3; Ely, E. Wesley MD, MPH4; Myatra, Sheila Nainan MD, FCCM, FICCM5; Salluh, Jorge I.F. MD, PhD6; Amare, Dawit MD7; Azoulay, Elie MD, PhD8; Bellelli, Giuseppe MD2,9; Csomos, Akos MD, PhD10; Fan, Eddy MD, PhD11,12; Fagoni, Nazzareno MD,PhD3; Girard, Timothy D. MD, MSCI13; Heras La Calle, Gabriel MD14; Inoue, Shigeaki MD, PhD, MSCI15; Lim, Chae-Man MD, PhD, FCCM16; Kaps, Rafael MD17; Kotfis, Katarzyna MD, PhD18; Koh, Younsuck MD16; Misango, David MD19; Pandharipande, Pratik P. MD, MSCI20; Permpikul, Chairat MD21; Cheng Tan, Cheng MD, PhD22; Wang, Dong-Xin MD, PhD22; Sharshar, Tarek MD, PhD23; Shehabi, Yahya PhD, FCICM, FANZCA, EMBA24,25; Skrobik, Yoanna MD, FRCP(c) MSc, FCCM26,27; Singh, Jeffrey M. MD28,29; Slooter, Arjen MD, PhD30; Smith, Martin MBBS, FRCA, FFICM31; Tsuruta, Ryosuke MD, PhD32; Latronico, Nicola MD33,34

doi: 10.1097/CCM.0000000000002640
Online Clinical Investigations

Objectives: To assess the knowledge and use of the Assessment, prevention, and management of pain; spontaneous awakening and breathing trials; Choice of analgesia and sedation; Delirium assessment; Early mobility and exercise; and Family engagement and empowerment (ABCDEF) bundle to implement the Pain, Agitation, Delirium guidelines.

Design: Worldwide online survey.

Setting: Intensive care.

Intervention: A cross-sectional online survey using the Delphi method was administered to intensivists worldwide, to assess the knowledge and use of all aspects of the ABCDEF bundle.

Measurement and Main Results: There were 1,521 respondents from 47 countries, 57% had implemented the ABCDEF bundle, with varying degrees of compliance across continents. Most of the respondents (83%) used a scale to evaluate pain. Spontaneous awakening trials and spontaneous breathing trials are performed in 66% and 67% of the responder ICUs, respectively. Sedation scale was used in 89% of ICUs. Delirium monitoring was implemented in 70% of ICUs, but only 42% used a validated delirium tool. Likewise, early mobilization was “prescribed” by most, but 69% had no mobility team and 79% used no formal mobility scale. Only 36% of the respondents assessed ICU-acquired weakness. Family members were actively involved in 67% of ICUs; however, only 33% used dedicated staff to support families and only 35% reported that their unit was open 24 hr/d for family visits.

Conclusions: The current implementation of the ABCDEF bundle varies across individual components and regions. We identified specific targets for quality improvement and adoption of the ABCDEF bundle. Our data reflect a significant but incomplete shift toward patient- and family-centered ICU care in accordance with the Pain, Agitation, Delirium guidelines.

1Department of Rehabilitation, Ancelle Hospital, Cremona, Italy.

2Geriatric Research Group, Brescia, Italy.

3Department of Anesthesia, Critical Care and Emergency, SpedaliCivili University Hospital, Brescia, Italy.

4Division of Pulmonary and Critical Care and Health Services Research, Vanderbilt University and VA Geriatric Research Education Clinical Center (GRECC), Nashville, TN.

5Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Mumbai, India.

6Department of Critical Care, D’or Institute for Research and Education and Post-Graduate Program Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.

7Addis Hiwot General Hospital, Addis Ababa, Ethiopia.

8Medical Intensive Care Unit, Hôpital Saint-Louis, ECSTRA team, Biostatistics and clinical epidemiology, UMR 1153 (Center of Epidemiology and Biostatistics Sorbonne Paris Cité, CRESS), INSERM, Paris Diderot Sorbonne University, Paris, France.

9School of Medicine and Surgery, University of Milano-Bicocca, Milano Geriatric Clinic, San Gerardo University Hospital, Monza, Italy.

10Department of Anaesthesia and Intensive Care, Medical Centre, Hungarian Defence Force, Budapest, Hungary.

11Interdepartmental Division of Critical Care Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.

12University Health Network, Toronto, ON, Canada.

13CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh and UPMC Health System, Pittsburgh, PA.

14International Research Project Humanizing Intensive Care (Proyecto HU-CI), Intensive Care Unit, Hospital Universitario de Torrejón, Madrid. Spain.

15Department of Emergency and Critical Care Medicine, Tokai University, School of Medicine, Kanagawa, Japan.

16Department of Pulmonary and Critical Care Medicine Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.

17General Hospital Novo mesto, Novo mesto, Slovenia.

18Department of Anaesthesia, Intensive Care and Acute Poisioning, Pomeranian Medical University, Szczecin, Poland.

19Aga Khan University Hospital, Nairobi, Kenya.

20Department of Anesthesiology, Division of Anesthesiology Critical Care Medicine Vanderbilt University Medical Center, Nashville, TN.

21Siriraj Hospital, Bangkok, Thailand.

22Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China.

23Department of Intensive Care Medicine Raymond Poincaré Hospital, Paris, France.

24School of Clinical Sciences, Faculty of Medicine, Monash University & Medical Center, Melbourne, VIC, Australia.

25University New South Wales, Clinical School of Medicine, NSW, Australia.

26Department of Medicine, McGill University, Montreal, QC, Canada.

27Regroupement de Soins Critiques Respiratoires, Réseau de Santé Respiratoire FRQS, Montreal, QC, Canada.

28Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.

29Krembil Neuroscience Centre, University Health Network, Toronto, ON, Canada.

30Department of Intensive Care Medicine, Brain Center Rudolf Magnus, Utrecht University, University Medical Center Utrecht, The Netherlands.

31Department of Neurocritical Care, University College London Hospitals, UCLH/UCL National Institute for Health Research Biomedical Research Centre, London, United Kingdom.

32Acute & General Medicine, Yamaguchi Graduate School of Medicine, Yamaguchi, Japan.

33Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy.

34Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy.

All authors contributed in study conception; design and critically revised the article; and interpretation of results. Drs. Morandi and Piva have equally contributed as first authors to the article and drafted the article and in acquisition of data.

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Dr. Ely’s institution received funding from Veterans Affairs Geriatric Research Education and Clinical Centers and the National Institutes of Health (NIH) (R01AG035117 and R01HL111111); he received funding from Orion, Abbott, and Pfizer; and he received support for article research from the NIH. Dr. Azoulay’s institution received research grant funding from Fisher & Paykel, Pfizer, Gilead, and Alexion, and he received funding for board member lectures from Alexion, Astellas, and Gilead. Dr. Fan is supported by a New Investigator Award from the Canadian Institutes of Health Research. Dr. Pandharipande’s institution received funding from Hospira Inc in collaboration with the NIH for a research grant. Dr. Pandharipande (R01HL111111 and R01AG035117) and Dr. Needham (R24HL111895 and R24AG054259) are supported by the NIH. Dr. Permpikul disclosed government work. Dr. Shehabi reported related unrestricted research and educational grants from Pfizer and Orion Pharma and the National Health and Medical Research Council of Australia. Speaker’s honorarium and travel expenses reimbursed to employing institution. Dr. Slooter works on the development of an EEG-based delirium monitor, any (future) profits of this technology will be used for future scientific research only, and he is supported by the European Society of Intensive Care Medicine, Technology Foundation STW (14066) and the European Union (H2020-PHC-12-2014-672974). The remaining authors have disclosed that they do not have any potential conflicts of interest.

Address requests for reprints to: Alessandro Morandi MD, MPH, Via Aselli 16, Cremona, 26100. E-mail:

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