There is strong, recent, convincing evidence that delirium, immobility, sedation, and ventilator management are closely interrelated. The purpose of this study was to evaluate the efficacy and safety of the ABCDE bundle in critically-ill patients receiving mechanical ventilation.
We hypothesized that implementation of the ABCDE bundle would result in improved patient outcomes.
This prospective, cohort, before-after study was conducted at a large, tertiary medical center located in the Midwestern United States. Subjects were recruited from 5 adult intensive care units (ICUs), 1 progressive care unit, and another unit that cared for critically-ill immunocompromised patients. A total of 186 (93 pre- and 94 post-ABCDE bundle implementation) mechanically ventilated patients were included in this analysis. The primary endpoint, defined a priori, was ventilator free days.
Baseline characteristics including age, APACHE II score, Charlson Comorbidity Score, and sedative drug use prior to enrollment were similar between the two groups. After ABCDE bundle implementation, patients were more likely to receive a spontaneous awakening trial [Pre N=35 (53%) vs. Post N=42 (71.2%); p=0.0372], a spontaneous breathing trial [Pre N=65 (70.7%) vs. Post N=79 (84%); p=0.0290], and get out of bed at least once during their ICU stay [N=44 (47.3%) vs. Post N=57 (60.6%); p-0.0675]. Patients in the post ABCDE bundle group spent more days breathing without ventilator assistance than those in the pre group [24 days vs. 21 days; p=0.0371]. Patients treated with the ABCDE bundle were less likely to experience delirium [Pre N=70 (75.3%) vs. Post N=62 (66.0%); p=0.1623] and spent significantly fewer days delirious [Pre N=2 (1, 5) vs. Post N=1 (0, 3); p=0.00437]. No significant differences in the time to ICU or hospital discharge, incidence or duration of coma, or change in residence were noted between groups. ICU mortality was higher in the pre (N=24, 25.8%) vs. post (N= 14 14.9%) group (p=0.0913). Six subjects (6.5%) in the pre- and 5 (5.3%) in the post ABCDE bundle period self-extubated (p=0.7421). The number of subjects who self-extubated who later required reintubation did not differ between groups [Pre N=1 (1.1%) vs. Post N=1 (1.1%); p=0.9999].
Our results suggest patients treated with the ABCDE bundle experience more days breathing without assistance and a shorter duration of ICU delirium. Adoption of this interprofessional, multicomponent bundle into everyday clinical care is warranted.