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Delirium Prevention and Safety:
Starting with the ABCDEF’s

It is essential to consider delirium management in the broader picture of ICU patient care as a major piece of the current guidelines for Pain, Agitation, and Delirium (PAD) of the Society of Critical Care Medicine (SCCM). Advancements in research and technology are resulting in higher acuity and increased complexity of care, which is resulting in drastic increases in workload and demands on staff. More than ever, there is a great need to develop simpler ways of implementing safer and better care into practice for our sickest patients.

The ABCDEF bundle is one way to align and coordinate care, which includes specific focus on delirium as a component of the overall care patients receive including sedation and pain medications, breathing machines, and mobilization.

What are the components of the ABCDEF bundle?

See menu on the left for more information on each component


Assess, Prevent, and Manage Pain
There are validated tools that are recommended that can be used in every patient every day.


Both Spontaneous Awakening Trials & Spontaneous Breathing Trials
This means providing these powerful medications when needed but stopping them when unnecessary to avoid over-use and unwanted side effects.


Choice of Analgesia and Sedation
Published evidence helps the team decide which are the safest sedatives and analgesics to use and which are the most important medications to avoid for a specific patient’s circumstances.


Delirium: Assess, Prevent and Manage
There are validated tools that are recommended that can be used in every patient every day. We will dive deeper into this aspect, DELIRIUM, in the page below.


Early Mobility and Exercise
This step involves optimizing mobility and exercise for every patient to the best of her or his ability (through the help of any member of the team assigned to perform this piece of care) and advancing that daily as clinically able.


Family Engagement and Empowerment
Good communication with the family is critical at every step of a patient’s clinical course, and empowering the family to be part of the team to ensure best care is adhered to diligently will improve many aspects of the patient’s experience. The F was recently added to help to keep patients and families as the center and focus of care.

(See menu on the left for more information on each component)

ABCDEF Resources

The F Component is not included in some of the older resources.


The PAD and ABCDEF table


Bedside Checklist


Education Handout


Education Slides


Pocket Reference


Wake Up and Breathe Flowchart

Spontaneous Awakening Trials (SATs) + Spontaneous Breathing Trials (SBTs)


Example Rounding Tool

ICU Liberation


Patient-Centered Rounds Using the ABCDEF Bundle


Example Video 1


Example Video 2


Example Video 3


Improving Hospital Survival and Reducing Brain Dysfunction at Seven California Community Hospitals: Implementing PAD Guidelines Via the ABCDEF Bundle in 6,064 Patients.

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The Science, Why, and What of ICU Liberation and the ABCDEF Bundle for Patients and Families

Dr. Wes Ely Hawaii SCCM 2017 Plenary

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AACN Resources: Implementing the ABCDE Bundle at the Bedside

The American Association of Critical Care Nurses (AACN) has put together a toolkit for implementing the ABCDE bundle at the bedside. This toolkit includes both resources for the specific components of the bundle as well as tools for change/implementation. It has been endorsed by the Agency for Healthcare Research and Quality (AHRQ)

AACN ABCDE Implementation Toolkit

Reducing iatrogenic risks: ICU-acquired delirium and weakness-crossing the quality chasm.

Vasilevskis EE et al. Chest. 2010
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Critical Care Nurses’ Role in Implementing the ABCDEF Bundle

Balas MC et al., Crit Care Nurse. 2012
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Implementing the 2013 PAD guidelines: top ten points to consider.

Pun BT, Balas MC, Davidson J, Semin Respir Crit Care Med. 2013
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Effectiveness and Safety of the Awakening and Breathing Coordination, Delirium Monitoring/Management, and Early Exercise/Mobility Bundle

Balas MC, Vasilevskis EE, Olsen KM, Schmid KK, Shostrom V, Cohen MZ, Peitz G, Gannon DE, Sisson J, Sullivan J, Stothert JC, Lazure J, Nuss SL, Jawa RS, Freihaut F, Ely EW, Burke WJ .Crit Care Med. 2014 Jan 3
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ICU Delirium Viewed Through the Lens of the PAD Guidelines and the ABCDEF Implementation Bundle

Critical Care Medicine 2015

A screening, prevention, and restoration model for saving the injured brain in intensive care unit survivors

Vasilevskis EE, Pandharipande PP, Girard TD, Ely EW. Crit Care Med. 2011 Oct 10
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Sedation, Delirium and Mechanical Ventilation: the 'ABCDE' Approach

Morandi A, Brummel NE, Ely EW. Crit Care Med. 2011 Feb 17
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Think of the ABCDEFs as a means of putting best practice into the real world of your ICU. Why use a mnemonic? Because it provides a sticky (i.e., easy to remember) message, and it is evidence based (all created from data published in high impact journals such as JAMA, Lancet, and NEJM). Outcomes of mechanically ventilated patients can be improved if the interventions described in the ABCDEF approach are used together as a bundle (M Balas CCM 2014) and discussed regularly on rounds with your interdisciplinary team. To ensure that bundles remain scientifically credible and have the maximum possible impact on outcomes, periodic updating based on new evidence is critical. The ABCDEF bundle, in accordance with the Society of Critical Care Medicine’s 2013 Clinical Practice Guidelines for the Management of Pain/Agitation/Delirium (PAD) in Adult ICU Patients, must include routine pain, agitation, and delirium screening and management through the use of valid and reliable tools. These tools are well outlined in the PAD Guidelines and many are available on this website.

So what is a BUNDLE anyway?

This is a published conversation that took place within the largest quality improvement organization in the U.S. called the Institute for Healthcare Improvement (IHI). The IHI's Rethinking Critical Care program has incorporated concepts related to the ABCDEFs and the PAD Guidelines that can be found on their website.

Three commonly misunderstood aspects of the ABCDEFs are as follows:

  • MYTH: The ABCDEFs and PAD are advocating different things.
  • TRUTH: These are similar constructs. As noted above, think of the ABCDEFs as a way of operationalizing the 2013 PAD guidelines. There are many ways of going about this; the ABCDEF Bundle is just one way of talking about and organizing this “new culture” of lighter sedation, attention to delirium, and early mobility. Just like the PAD does advocate early mobility even though mobility is not explicitly stated in the title, so Pain is also included in the ABCDEFs even though that mnemonic doesn’t include a “P.”

  • MYTH: If an ICU is not completely turning off sedative medications, it is not embracing SATs or the ABCDEFs.
  • TRUTH: The original ABC study, as well as other subsequent publications and quality improvement projects have prioritized the concept of a “complete shut off” of sedation and analgesia once the patient is felt to be pain free and passes the SAT safety screen. However, there are hospitals in general or specific patients in whom a reduction in sedative dose without a complete shut-off is indicated for safety reasons. This SAT and SBT approach supported by the NEJM and Lancet studies is not a “one shoe fits all.” We must use clinical judgment. If the reason we are leaving the potent sedative medications going in our patients is mostly because “that is our culture” or the staff are too busy to deal with an interactive patient, then that likely needs to be re-evaluated and solutions found.

Assess and Treat Pain