NEW ORLEANS — The addition of a family component to the ABCDE bundle decreases ventilator time and improves weaning, delirium assessment, treatment, and patient mobility, according to a new study.

"When we looked at the ABCDE bundle, we said, there's only one thing missing — and that's how we work with the patient's family," said Erica Edwards, RN, an attending nurse at the Massachusetts General Hospital in Boston.

The ABCDE bundle is a way to coordinate the effort of multiple disciplines in the management of critically ill patients, Edwards explained here at the American Association of Critical-Care Nurses (AACN) 2016 National Teaching Institute and Critical Care Exposition.

The bundle was designed to reduce oversedation, immobility, and the development of delirium, all of which harm patients. It was initially presented at the AACN 2012 Annual National Teaching Institute and Critical Care Exposition, as reported by Medscape Medical News.

For their study, Edwards and a team of nurses initiated an extensive education program on the new ABCDE+F bundle in nine hospital intensive care units at the Massachusetts General Hospital. Sessions highlighted the family component of the bundle.

Components of the ABCDE+F Bundle
A Assess and manage pain using the Behavioral Pain Scale and Critical Care Pain Observation Tool
B Spontaneous breathing trials
C Choice of sedation; use lighter sedation and analgosedation, and treat pain first
D Delirium assessment and management, using validated assessment tools (CAM-ICU or ICDSC) and treatment and prevention options
E Early exercise and progressive mobility
F Family engagement and empowerment; involve the family in all aspects of the bundle to assess and assist the patient


To foster collaboration, an attending nurse met daily with each member of the patient's care team and then explained to dedicated family members what the day looked like, updated them on the current situation, and suggested how they could help. The family was also involved in the development of an individualized patient plan.

An open family visitation policy was established, and rooms were made available for family members to facilitate continuous visitation. Family members were encouraged to help mobilize patients, keep them active during the day to regulate their sleep–wake cycle, and be there when patients were taken off ventilation.

The program had a ripple effect, Edwards told Medscape Medical News. First, nurses were made more aware of the bundle and learned to implement evidence-based practices. Second, they helped family members become aware of ways to support loved ones by supporting hospital efforts and providing patient information and cues.

"While we've always had a culture of family inclusion, with these new guidelines, we feel we can do what we do even better," Edwards reported.

Families serve the care team in many ways. They can facilitate communication and can tell staff about the patient's condition when the patient cannot. They can act as protectors of patients, watching over them and advocating for them. They are historians and can explain the patient's history and provide clues to their changed state. They can also be facilitators, coaches providing inner strength, and voluntary caregivers.

"It isn't always easy," said Edwards. "But family members always tell us they are so grateful we let them stay and keep them updated and, in turn, we get so much information from them."

Cost Savings

The program paid off. National averages show that one ventilator day costs an average of $1522. The first quarter the ABCDE+F bundle was implemented, the nurses reported a 1.21% reduction in ventilator days, resulting in a 50-day reduction in ventilation. This led to a projected annual cost savings for the hospital of $304,400.

Family can touch the patient, ground them, and reduce the incidence of delirium.

There was no change in length of hospital stay, but Edwards said she attributes this to the fact that the hospital was at 95% capacity when they rolled out the program, so there was nowhere to move patients.

There were 790,257 hospitalizations involving mechanical ventilation in the United States in 2005, which cost an estimated $27 billion, or 12% of all hospital costs, she reported.

The annual cost of delirium healthcare in the United States is $143 billion. "And we know that there are many longer-term cognitive and physiological effects of having delirium while on a ventilator," she pointed out.

"If you think back, many of us started wanting to include family in the 1970s, with the Molter family needs assessment study" (Heart Lung. 1979;8:332-339), said Mary Lou Sole, PhD, RN, dean of the University of Central Florida College of Nursing and the Orlando Health Endowed Chair in Nursing. "But it took us until 2016 to include it in the bundle."

"Having a comprehensive approach with family will lead to better outcomes," Dr Sole explained. "Family can touch the patient, ground them, and reduce the incidence of delirium."

With technology, gadgets, and devices, care has become more complex. And more patients are critically ill because more people are being saved. "Using family to help assess and communicate with patients to help facilitate early extubation with minimum sedation is better for everyone," she said.

Ms Edwards and Dr Sole do not have any relevant financial relationships to disclose.

American Association of Critical-Care Nurses (AACN) National Teaching Institute and Critical Care Exposition. Presented May 17, 2016.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.