Factors Associated with ABCDEF Bundle Implementation for Critically Ill Patients: An International Cross-sectional Survey in 54 Countries

Overview

Journal SAGE Open Med

Publisher Sage Publications

Date 2025 Jan 10

PMID 39790294

Authors

Junpei Haruna

Takeshi Unoki

Keibun Liu

Kensuke Nakamura

Shigeaki Inoue

Osamu Nishida

Affiliations

Soon will be listed here.

Abstract

Objectives: This study investigated the implementation of the ABCDEF bundle and the factors associated with its implementation according to national income levels.

Methods: This study is cross-sectional research. We conducted a secondary analysis of an international 1-day point-prevalence study that investigated the implementation of the ABCDEF bundle in critically ill patients. All patients admitted to the ICU were eligible. This study was conducted across 135 ICUs in 54 countries, including data from 664 patients. Outcomes were categorized according to the income level of the country (high-income, middle-income, and low-income countries) in which each ICU was located. A multilevel generalized linear model was developed to identify the factors associated with ABCDEF bundle implementation for each income level.

Results: We identified 664 patients in 79 high-income countries, 278 in 26 middle-income countries, and 287 in 30 low-income countries ICUs. Implementation rates of the ABCDEF bundle were low for all income levels but varied. Few individuals completed the entire bundle on the survey date. Common factors associated with the implementation among all income levels were a multidisciplinary team approach for Element A (pain) and mechanical ventilation use for Element C (sedation), which were also associated with lower Element E (mobility). The existence of a protocol was frequently identified as a promoting factor associated with ABCDEF bundle implementation. The associated factors varied by income level; for example, dedicated intensivists were only identified in high-income countries, but not in middle-income countries or low-income countries.

Conclusions: The overall low ABCDEF bundle implementation rates necessitate action. As factors associated with its implementation vary according to national income level, tailored strategies are essential for improving ICU care quality.

Trial Registration: NA.

References

Inoue S, Hatakeyama J, Kondo Y, Hifumi T, Sakuramoto H, Kawasaki T . Post-intensive care syndrome: its pathophysiology, prevention, and future directions. Acute Med Surg. 2019; 6(3):233-246. PMC: 6603316. DOI: 10.1002/ams2.415. View

Jeffery A, Werthman J, Danesh V, Dietrich M, Mion L, Boehm L . Assess, Prevent, and Manage Pain; Both Spontaneous Awakening and Breathing Trials; Choice of Analgesia/Sedation; Delirium: Assess, Prevent, and Manage; Early Mobility; Family Engagement and Empowerment Bundle Implementation: Quantifying the.... Crit Care Explor. 2021; 3(9):e0525. PMC: 8443813. DOI: 10.1097/CCE.0000000000000525. View

Liu K, Ogura T, Takahashi K, Nakamura M, Ohtake H, Fujiduka K . The safety of a novel early mobilization protocol conducted by ICU physicians: a prospective observational study. J Intensive Care. 2018; 6:10. PMC: 5819168. DOI: 10.1186/s40560-018-0281-0. View

Morandi A, Piva S, Wesley Ely E, Myatra S, Salluh J, Amare D . Worldwide Survey of the "Assessing Pain, Both Spontaneous Awakening and Breathing Trials, Choice of Drugs, Delirium Monitoring/Management, Early Exercise/Mobility, and Family Empowerment" (ABCDEF) Bundle. Crit Care Med. 2017; 45(11):e1111-e1122. PMC: 5640479. DOI: 10.1097/CCM.0000000000002640. View

Liu K, Nakamura K, Katsukawa H, Nydahl P, Ely E, Kudchadkar S . Implementation of the ABCDEF Bundle for Critically Ill ICU Patients During the COVID-19 Pandemic: A Multi-National 1-Day Point Prevalence Study. Front Med (Lausanne). 2021; 8:735860. PMC: 8581178. DOI: 10.3389/fmed.2021.735860. View

Barnes-Daly M, Phillips G, Wesley Ely E . Improving Hospital Survival and Reducing Brain Dysfunction at Seven California Community Hospitals: Implementing PAD Guidelines Via the ABCDEF Bundle in 6,064 Patients. Crit Care Med. 2016; 45(2):171-178. DOI: 10.1097/CCM.0000000000002149. View

Bakhru R, McWilliams D, Wiebe D, Spuhler V, Schweickert W . Intensive Care Unit Structure Variation and Implications for Early Mobilization Practices. An International Survey. Ann Am Thorac Soc. 2016; 13(9):1527-37. PMC: 5059498. DOI: 10.1513/AnnalsATS.201601-078OC. View

Liu K, Ogura T, Takahashi K, Nakamura M, Ohtake H, Fujiduka K . A Progressive Early Mobilization Program Is Significantly Associated With Clinical and Economic Improvement: A Single-Center Quality Comparison Study. Crit Care Med. 2019; 47(9):e744-e752. DOI: 10.1097/CCM.0000000000003850. View

Peris A, Bonizzoli M, Iozzelli D, Migliaccio M, Zagli G, Bacchereti A . Early intra-intensive care unit psychological intervention promotes recovery from post traumatic stress disorders, anxiety and depression symptoms in critically ill patients. Crit Care. 2011; 15(1):R41. PMC: 3221970. DOI: 10.1186/cc10003. View

10.

Marino J, Bucher D, Beach M, Yegneswaran B, Cooper B . Implementation of an Intensive Care Unit Delirium Protocol: An Interdisciplinary Quality Improvement Project. Dimens Crit Care Nurs. 2015; 34(5):273-84. DOI: 10.1097/DCC.0000000000000130. View

11.

Foster C, Simone S, Bagdure D, Garber N, Bhutta A . Optimizing Team Dynamics: An Assessment of Physician Trainees and Advanced Practice Providers Collaborative Practice. Pediatr Crit Care Med. 2016; 17(9):e430-6. DOI: 10.1097/PCC.0000000000000881. View

12.

Lavallee J, Gray T, Dumville J, Russell W, Cullum N . The effects of care bundles on patient outcomes: a systematic review and meta-analysis. Implement Sci. 2017; 12(1):142. PMC: 5707820. DOI: 10.1186/s13012-017-0670-0. View

13.

Balas M, Burke W, Gannon D, Cohen M, Colburn L, Bevil C . Implementing the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle into everyday care: opportunities, challenges, and lessons learned for implementing the ICU Pain, Agitation, and Delirium.... Crit Care Med. 2013; 41(9 Suppl 1):S116-27. PMC: 4096994. DOI: 10.1097/CCM.0b013e3182a17064. View

14.

Wesley Ely E . The ABCDEF Bundle: Science and Philosophy of How ICU Liberation Serves Patients and Families. Crit Care Med. 2017; 45(2):321-330. PMC: 5830123. DOI: 10.1097/CCM.0000000000002175. View

15.

Kleinpell R, Wesley Ely E, Grabenkort R . Nurse practitioners and physician assistants in the intensive care unit: an evidence-based review. Crit Care Med. 2008; 36(10):2888-97. DOI: 10.1097/CCM.0b013e318186ba8c. View

16.

Alberto Cerqueira Batista Filho L . Critical care in developing nations: what has the COVID-19 pandemic revealed?. Pan Afr Med J. 2023; 45:123. PMC: 10543904. DOI: 10.11604/pamj.2023.45.123.40574. View

17.

Valentin A, Ferdinande P . Recommendations on basic requirements for intensive care units: structural and organizational aspects. Intensive Care Med. 2011; 37(10):1575-87. DOI: 10.1007/s00134-011-2300-7. View

18.

Pronovost P, Angus D, Dorman T, Robinson K, Dremsizov T, Young T . Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review. JAMA. 2002; 288(17):2151-62. DOI: 10.1001/jama.288.17.2151. View

19.

Girard T, Thompson J, Pandharipande P, Brummel N, Jackson J, Patel M . Clinical phenotypes of delirium during critical illness and severity of subsequent long-term cognitive impairment: a prospective cohort study. Lancet Respir Med. 2018; 6(3):213-222. PMC: 6709878. DOI: 10.1016/S2213-2600(18)30062-6. View

20.

Wunsch H, Gershengorn H, Scales D . Economics of ICU organization and management. Crit Care Clin. 2011; 28(1):25-37, v. PMC: 3665001. DOI: 10.1016/j.ccc.2011.09.004. View