ABCDE Bundle: Improving Outcomes for Ventilated Patients

An Expert Interview With Chandra Alexander RN, CCRN, and Dena Putnam, RN, BA, MBA

Elizabeth McGann, DNSc, RN

June 14, 2012

June 14, 2012 — Editor's note: Oversedation, immobility, and delirium have serious implications for critically ill patients who are on mechanical ventilation. There is a protocol that can lessen these conditions and improve patient outcomes. "Now I Know My ABCs...Implementing the ABCDE Bundle to Improve Ventilator Weaning, Delirium, and Mobility in the ICU" was featured as a podium presentation at the American Association of Critical-Care Nurses (AACN) 2012 Annual National Teaching Institute and Critical Care Exposition, held May 19 to 24 in Orlando, Florida.

To find out more about what the ABCDE bundle can mean in the care of critically ill patients, Medscape Medical News interviewed Chandra Alexander, RN, CCRN, and Dena Putnam, RN, BA, MBA.

Alexander has extensive experience as a charge nurse and assistant manager of the intensive care unit (ICU) at the McKenzie Willamette Medical Center in Springfield, Oregon. She has been an active member of the unit practice committee and has been involved in process improvement projects for more than 5 years.

Putnam is manager of the ICU at the McKenzie Willamette Medical Center. She has more than 20 years of nursing experience, including positions as assistant director of staff development, and 10 years in quality and risk services. Putnam has led hospital-wide quality improvement projects and has implemented the hospital's medical staff peer-review process.

Medscape: What is the ABCDE bundle?

Alexander and Putnam: The ABCDE bundle is a coordinated effort between multiple disciplines for the management of critically ill patients. Its utilization is aimed at reducing oversedation, immobility, and the development of delirium, all of which harm patients.

The ABCDE bundle involves the following.

A: Awakening trials for ventilated patients.
B: Spontaneous breathing trials.
C: Coordinated effort between the registered nurse and respiratory therapist to perform the spontaneous breathing trial when the patient is awakened by reducing or stopping the patient's sedation. The combination of sedation and analgesics being used are reviewed, and changes or reductions in the doses are considered.
D: A standardized delirium assessment program, including treatment and prevention options.
E: Early mobilization and ambulation of critical care patients.

Medscape: How does the ABCDE bundle contribute to ventilator weaning, the management of delirium, and early ambulation in the ICU?

Alexander and Putnam: This is a defined and coordinated bundle that facilitates the registered nurse, physician, respiratory therapist, and physical therapist to work together to improve outcomes by reducing ICU-related complications. Ventilator weaning occurs faster because patients are less likely to be oversedated, which reduces total ventilator days (and its associated complications). Delirium, which research indicates can last as long as a year after discharge from the hospital, can be reduced by identifying patients who develop it and aggressively managing it with medication adjustments and patient care planning. The early ambulation portion of the ABCDE bundle is a 6-step process that starts as early as hospital day 1 and progresses until the critical care patient is ambulating — even those who are ventilated. This reduces muscle wasting, decreasing total ventilator days.

Medscape: What were the challenges of implementing this protocol?

Alexander and Putnam: Executive and multidisciplinary manager approvals were needed for successful implementation. It took time to strategically plan the development and implementation of the program and to get all the disciplines to approve the protocol and dedicate the resources needed for success. Once that was accomplished, developing and coordinating multidisciplinary education was time consuming.

Ultimately, all the work done before the roll out with the front-line staff paid off. The process was seamless and implementation went better than expected.

There were a few glitches as the bundle was implemented on the first patients. Not all patients perfectly met the criteria for bundle implementation. Nonetheless, a case-by-case evaluation of each patient resulted in implementing the bundle. Staff needed continued guidance and support through the process, especially the early ambulation process, since this was a new concept for the newer nurses and respiratory therapists.

Medscape: What have the primary outcomes been?

Alexander and Putnam: We implemented the ABCDE bundle May 1, 2011, and our first set of outcomes reflect 6 months of bundle data. The 2011 case-mix index was the same as it was 2010. Improved outcomes included a 32% drop in ventilator days, the death rate decreased 10%, and the average length of stay for the ICU went from 2.55 days to 2.31 days. There were no ventilator-associated pneumonias (VAP).

Medscape: How do staff, patients, and families respond to the ABCDE bundle?

Alexander and Putnam: Initially, staff were reluctant to implement the bundle, especially with very critical patients. Over time, it has become part of standard daily care. All patients are considered eligible for the ABCDE bundle and must be "ruled out" of any or all elements of the bundle.

Patients and families have responded with enthusiasm to getting out of bed and being awake. They think it is a normal process of their care.

A significant concern from the hospital staff was the possibility of self-extubation of awake and ambulating patients. Thus far, there have been no adverse outcomes with patients being awake and ambulating.

Medscape: What resources are available to healthcare providers who would like to learn more about the ABCDE Bundle?

Alexander and Putnam: AACN Practice Alerts has information on the ABCDE bundle, Vanderbilt University has a Web site dedicated to delirium, and the Institute for Healthcare Improvement has a good Web site for research.

Medscape: What were the 2 most significant aspects of your presentation?

Alexander and Putnam: The actual implementation process steps and the positive outcomes were the most important. The ABCDE bundle decreased our ventilator days, death rate, ICU days, and maintained a zero VAP rate.

Alexander and Putnam have disclosed no financial relationships.

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