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

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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

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Critical Care Medicine 47(1):p 3-14, January 2019. | DOI: 10.1097/CCM.0000000000003482



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.


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


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


15,226 adults with at least one ICU day.


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).


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.

Copyright © 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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