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Caring for Critically Ill Patients with the ABCDEF Bundle: Results of the ICU Liberation Collaborative in Over 15,000 Adults

Pun, Brenda T. DNP, RN, FCCM1; Balas, Michele C. PhD, RN, CCRN-K, FCCM, FAAN2,3; Barnes-Daly, Mary Ann MS, RN, CCRN-K, DC4; Thompson, Jennifer L. MPH5; Aldrich, J. Matthew MD6; Barr, Juliana MD, FCCM7,8; Byrum, Diane MSN, RN, CCRN-K, CCNS, FCCM9; Carson, Shannon S. MD10; Devlin, John W. PharmD, FCCM11; Engel, Heidi J. PT, DPT12; Esbrook, Cheryl L. OTR/L, BCPR13; Hargett, Ken D. MHA, FAARC, FCCM14; Harmon, Lori RRT, MBA, CPHQ15; Hielsberg, Christina MA15; Jackson, James C. PsyD1; Kelly, Tamra L. BS, RRT, MHA4; Kumar, Vishakha MD, MBA15; Millner, Lawson RRT16; Morse, Alexandra PharmD4; Perme, Christiane S. PT, CCS, FCCM14; Posa, Patricia J. BSN, MSA, CCRN-K17; Puntillo, Kathleen A. PhD, RN, FCCM, FAAN18; Schweickert, William D. MD19; Stollings, Joanna L. PharmD, FCCM20; Tan, Alai PhD2; D’Agostino McGowan, Lucy PhD21; Ely, E. Wesley MD, MPH, FCCM1,22

doi: 10.1097/CCM.0000000000003482
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Objective: Decades-old, common ICU practices including deep sedation, immobilization, and limited family access are being challenged. We endeavoured to evaluate the relationship between ABCDEF bundle performance and patient-centered outcomes in critical care.

Design: Prospective, multicenter, cohort study from a national quality improvement collaborative.

Setting: 68 academic, community, and federal ICUs collected data during a 20-month period.

Patients: 15,226 adults with at least one ICU day.

Interventions: We defined ABCDEF bundle performance (our main exposure) in two ways: 1) complete performance (patient received every eligible bundle element on any given day) and 2) proportional performance (percentage of eligible bundle elements performed on any given day). We explored the association between complete and proportional ABCDEF bundle performance and three sets of outcomes: patient-related (mortality, ICU and hospital discharge), symptom-related (mechanical ventilation, coma, delirium, pain, restraint use), and system-related (ICU readmission, discharge destination). All models were adjusted for a minimum of 18 a priori determined potential confounders.

Measurements and Results: Complete ABCDEF bundle performance was associated with lower likelihood of seven outcomes: hospital death within 7 days (adjusted hazard ratio, 0.32; CI, 0.17–0.62), next-day mechanical ventilation (adjusted odds ratio [AOR], 0.28; CI, 0.22–0.36), coma (AOR, 0.35; CI, 0.22–0.56), delirium (AOR, 0.60; CI, 0.49–0.72), physical restraint use (AOR, 0.37; CI, 0.30–0.46), ICU readmission (AOR, 0.54; CI, 0.37–0.79), and discharge to a facility other than home (AOR, 0.64; CI, 0.51–0.80). There was a consistent dose-response relationship between higher proportional bundle performance and improvements in each of the above-mentioned clinical outcomes (all p < 0.002). Significant pain was more frequently reported as bundle performance proportionally increased (p = 0.0001).

Conclusions: ABCDEF bundle performance showed significant and clinically meaningful improvements in outcomes including survival, mechanical ventilation use, coma, delirium, restraint-free care, ICU readmissions, and post-ICU discharge disposition.

1Department of Medicine, Pulmonary and Critical Care, Critical Illness, Brain dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN.

2The Ohio State University, College of Nursing, Columbus, OH.

3The Ohio State University Wexner Medical Center, Columbus, OH.

4Sutter Health, Sacramento, CA.

5Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN.

6Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA.

7Stanford University School of Medicine, Stanford, CA.

8VA Palo Alto Health Care System, Palo Alto, CA.

9Innovative Solutions for Healthcare Education, LLC, Charlotte, NC.

10University of North Carolina School of Medicine, Chapel Hill, NC.

11School of Pharmacy, Northeastern University and Division of Pulmonary and Critical Care Medicine, Tufts Medical Center, Boston, MA.

12Department of Rehabilitative Services, University of California, San Francisco, San Francisco, CA.

13University of Chicago Medicine, Chicago, IL.

14Houston Methodist Hospital, Houston, TX.

15Society of Critical Care Medicine, Mount Prospect, IL.

16Novant Health, Forsyth Medical Center, Winston-Salem, NC.

17Saint Joseph Mercy Health System, Ann Arbor, MI.

18Department of Physiological Nursing, School of Nursing, University of California, San Francisco, San Francisco, CA.

19Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.

20Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN.

21The Department of Biostatistics, Johns Hopkins University, Baltimore, MD.

22The Tennessee Valley Veteran’s Affairs Geriatric Research Education Clinical Center, Nashville, TN.

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Funding for the ICU Liberation ABCDEF collaborative was provided by the Gordon and Betty Moore Foundation and the Society of Critical Care Medicine. Grant support for REDCap UL1 TR000445 from NCATS/NIH.

Dr. Pun has received honoraria from Society of Critical Care Medicine (SCCM), American Association of Critical Care Nurses, and Michigan Hospital Association. Dr. Balas has received honoraria from SCCM, Michigan Hospital Association, Hospital of the University of Pennsylvania, and ANZICS/ACCCN Intensive Care ASM. Dr. Balas is currently receiving a grant from the American Association of Critical Care Nurses and is on the speaker’s bureau for the Medical Education Speaker’s Network. Dr. Balas’ institution received funding from the American Association of Critical Care Nurses (AACN) and Select Medical. Dr. Aldrich received funding from the NIH/National Heart, Lung, and Blood Institute (NHLBI), Dannemiller Anesthesiology Review Course, and National Association for Medical Direction of Respiratory Care (travel support and lecture honorarium), and he has past relationships with the following institutions (honoraria paid for visiting lectures): Massachusetts General Hospital, University of Manitoba, University of Calgary, and Washington Hospital, Fremont, CA. Dr. Barr received funding from Masimo Inc, Medasense, and Dignity Health. Dr. Barr is an Advisory Board Member for Medasense Biometrics, Ltd and a Scientific Advisor for Masimo, Inc. Ms. Byrum received funding from AACN (board member of the Certification Corporation [travel expenses to meetings] and annual conference honorarium and travel expenses). Dr. Devlin has received research funding from the National Institute of Aging, National Heart, Lung and Blood Institute, the Canadian Institute of Health Research, and Astra Zeneca; he is on the editorial board of Critical Care Medicine and is the president of the American Delirium Society. Dr. Carson received grants from the NIH and the Biomarck Corporation. Ms. Harmon’s, Ms. Hielsberg’s, Dr. Kumar’s, and Dr. Kelly’s institutions received funding from the Gordon and Betty Moore Foundation. Dr. Jackson received grant support from the NIH. Dr. Perme received funding from American Hospital Association-HRET and Michigan Hospital Association (both as subcontractor on the HIIN CMS contract). Dr. Puntillo received funding from the Geneva Foundation (consulting) and the University of Oslo (consulting). Dr. Schweickert reports being a consultant for Arjo Inc and has received funding from the American College of Physicians. Dr. Ely received grant support from the NIH, VA funding (from the Geriatric Research Education Clinical Center, GRECC), and other support from the Gordon and Betty Moore Foundation; he received funding from SCCM, Pfizer and Orion for CME activities. He has been on a Scientific Advisory Board for Masimo, Inc. Drs. Pun, Aldrich, Engel, Stollings, and Ely received funding from the SCCM/the Gordon and Betty Moore Foundation. Dr. Balas, Ms. Thompson, Ms. Byrum, Mr. Millner, Dr. Morse, Dr. Perme, Ms. Posa, Dr. Puntillo, and Dr. Schweickert received funding from SCCM. The remaining authors have disclosed that they do not have any potential conflicts of interest.

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