Staged Implementation of Awakening and Breathing, Coordination, Delirium Monitoring and Management, and Early Mobilization Bundle Improves Patient Outcomes and Reduces Hospital Costs

S. Jean Hsieh, MD, MS; Olufisayo Otusanya, MD; Hayley B. Gershengorn, MD; Aluko A. Hope, MD, MScE; Christopher Dayton, MD; Daniela Levi, MD; Melba Garcia, BSN; David Prince, MD; Michele Mills, MA, OTR; Dan Fein, MD; Silvie Colman, PhD; Michelle Ng Gong, MD, MS


Crit Care Med. 2019;47(7):885-893. 

In This Article

Abstract and Introduction


Objectives: To measure the impact of staged implementation of full versus partial ABCDE bundle on mechanical ventilation duration, ICU and hospital lengths of stay, and cost.

Design: Prospective cohort study.

Setting: Two medical ICUs within Montefiore Healthcare Center (Bronx, NY).

Patients: One thousand eight hundred fifty-five mechanically ventilated patients admitted to ICUs between July 2011 and July 2014.

Interventions: At baseline, spontaneous (B)reathing trials (B) were ongoing in both ICUs; in period 1, (A)wakening and (D)elirium (AD) were implemented in both full and partial bundle ICUs; in period 2, (E)arly mobilization and structured bundle (C)oordination (EC) were implemented in the full bundle (B-AD-EC) but not the partial bundle ICU (B-AD).

Measurements and Main Results: In the full bundle ICU, 95% patient days were spent in bed before EC (period 1). After EC was implemented (period 2), 65% of patients stood, 54% walked at least once during their ICU stay, and ICU-acquired pressure ulcers and physical restraint use decreased (period 1 vs 2: 39% vs 23% of patients; 30% vs 26% patient days, respectively; p < 0.001 for both). After adjustment for patient-level covariates, implementation of the full (B-AD-EC) versus partial (B-AD) bundle was associated with reduced mechanical ventilation duration (–22.3%; 95% CI, −22.5% to −22.0%; p < 0.001), ICU length of stay (–10.3%; 95% CI, −15.6% to −4.7%; p = 0.028), and hospital length of stay (–7.8%; 95% CI, −8.7% to −6.9%; p = 0.006). Total ICU and hospital cost were also reduced by 24.2% (95% CI, −41.4% to −2.0%; p = 0.03) and 30.2% (95% CI, −46.1% to −9.5%; p = 0.007), respectively.

Conclusions: In a clinical practice setting, the addition of (E)arly mobilization and structured (C)oordination of ABCDE bundle components to a spontaneous (B)reathing, (A)wakening, and (D) elirium management background led to substantial reductions in the duration of mechanical ventilation, length of stay, and cost.


ICU-acquired delirium and weakness can lead to devastating cognitive and physical impairments and psychiatric symptoms in ICU survivors, also known as "post-intensive care syndrome".[1–6] The (A)wakening and (B)reathing, (C)oordination, (D)elirium monitoring and management, and (E)arly mobilization (ABCDE) bundle[7,8] is an interdisciplinary patient-centered evidence-based strategy endorsed by critical care societies and national quality improvement agencies to prevent and reduce ICU delirium and weakness, and operationalize the Society of Critical Care Medicine's Pain, Agitation, and Delirium clinical practice guidelines.[9–13]

Individual components of the ABCDE bundle are associated with substantial benefits in research settings.[14–20] Although studies in clinical practice settings suggest that implementation of the full ABCDE bundle is associated with clinical benefits, its uptake has been limited and implementation often-incomplete.[21–28] Sequential implementation of bundle components may improve overall execution by allowing providers to: 1) maximize efficacy of implementation by focusing on individual components, 2) assess process improvement by performing stepwise evaluation of components, and 3) make practice adjustments before moving to the next component. In addition, studies suggest that the efficacy of early mobilization can be maximized if programs to reduce unnecessary sedation and delirium are already in place.[25,29]

Accordingly, we sought to determine the impact of adding EC to B-AD in the context of staged implementation of the ABCDE bundle in mechanically ventilated (MV) patients. We hypothesized that implementation of early mobilization on a foundation of targeted sedation practices and routine delirium monitoring would improve clinical outcomes and reduce hospital cost. Preliminary results have been presented in abstract form.[30,31]