Nancy A. Melville

January 22, 2013

SAN JUAN, Puerto Rico — Critically ill patients treated with the ABCDE bundle experience more days breathing without assistance and less delirium, according to research presented here at the Society of Critical Care Medicine 42nd Critical Care Congress.

The ABCDE bundle, first developed at Vanderbilt University in Nashville, Tennessee, incorporates interdisciplinary and multicomponent approaches to critical care.

It encourages awakening trials for ventilated patients, spontaneous breathing tests, coordination between care providers (including registered nurses and respiratory therapists), a standardized delirium assessment program, and early mobilization and ambulation.

The ABCDE bundle is a rational and evidenced-based way to manage sick, mechanically ventilated patients.

"There have been numerous studies looking at the variables, such as the benefits of cutting back on sedation and even letting people breath on their own once a day, every day," said lead author Michele Balas, PhD, RN, from the University of Nebraska Medical Center in Omaha. "We have found over the last 5 years that very aggressive early mobilization is especially effective in reducing the incidence and duration of delirium, but this is the first study demonstrating the outcome if you put all of these things together," she explained.

To assess the bundle's effectiveness, Dr. Balas and her team compared the outcomes of 186 critically ill patients. They were divided into 2 groups: those treated with traditional care and those treated with the ABCDE bundle approach.

Although baseline characteristics, including age, severity of illness, and sedative drug use, were similar in the 2 groups, patients in the ABCDE group spent more days breathing without ventilator assistance. In addition, rates of delirium and mortality in the intensive care unit were lower in the ABCDE group than in the traditional-care group.

Effect of ABCDE Bundle on Patient Outcomes

Outcome Without ABCDE
(= 93)
(= 94)
P Value
Received a spontaneous awakening trial 53% 71% .0372
Received a spontaneous breathing trial 71% 84% .0290
Got out of bed at least once 47% 61% .0675
Days spent breathing without ventilator 21 days 24 days .0371
Experienced delirium 75% 66% .1623
Length of delirium 2 days 1 day .00437
Died in the intensive care unit 25.8% 14.9% .0913
Self-extubated 6.5% 5.3% .7421

One patient in each group self-extubated and later required reintubation. There were no significant differences between groups in terms of time to intensive care or hospital discharge, incidence or duration of coma, or change in residence.

Though the ABCDE bundle is not yet in widespread use, these findings underscore its potential benefits, said session moderator Mitchell Fink, MD, vice chair of critical care and professor at the David Geffen School of Medicine, University of California in Los Angeles.

"The ABCDE bundle is a rational and evidenced-based way to manage sick, mechanically ventilated patients," said Dr. Fink. This study "seems to validate its effectiveness. Minimizing the use of sedatives, particularly benzodiazepines, seems to be very important, as does early mobilization of patients," he noted.

Standard of Care

"The ABCDE bundle, per se, is not yet the standard of care," Dr. Fink pointed out, "but many elements in it, such as early mobilization, spontaneous awakening trials, and spontaneous breathing trials, are widely viewed as such."

Dr. Balas told Medscape Medical News that the next phase of the research will evaluate the barriers to implementing the ABCDE bundle. She explained that "one would think that in such an intense work environment, communication would be in place, but we have found that one of the biggest challenges is communication."

To the address this problem, the researchers recommend that at least once a day all members of the interdisciplinary team get together to talk about a plan for that 24-hour period.

Another factor in implementing the bundle is awareness that delirium can have long-lasting effects, said Dr. Balas. "We were surprised that a lot of providers were not aware of the long-term consequences of critical care. I think we are so focused on saving lives that we may not take the time to think about what happens when the patient leaves the hospital and what their life is like in the long term."

Evidence suggests that intensive care delirium can have lifelong consequences. "Patients are at great risk of substantial functional decline — they are more likely to have to go to a nursing home and they have trouble maintaining social relationships and going back to work. It really is an emerging public health crisis, considering what this is doing to our society and how much it costs," Dr. Balas said.

This study was supported by a grant from the Robert Wood Johnson Foundation. Dr. Balas and Dr. Fink have disclosed no relevant financial relationships.

Society of Critical Care Medicine (SCCM) 42nd Critical Care Congress: Abstract 1. Presented January 20, 2013.