ABCDEF (A2F) Overview
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, Delirium, Immobility, and Sleep Disruption (PADIS) from 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 (A2F) 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 A2F bundle?
There are validated tools that are recommended that can be used in every patient every day.
This means providing powerful medications when needed but stopping them when unnecessary to avoid over-use and unwanted side effects.
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.
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.
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.
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.
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). The use of the A2F bundle is associated with clinically meaningful improvements in outcomes including survival, mechanical ventilation use, coma, delirium, restraint-free care, ICU readmissions, and post-ICU discharge disposition (B Pun CCM 2018, M.A. Barnes-Daly CCM 2017, M Balas CCM 2014). To ensure that bundles remain scientifically credible and have the maximum possible impact on outcomes, periodic updating based on new evidence is critical. The A2F bundle, in accordance with the Society of Critical Care Medicine’s 2018 Clinical Practice Guidelines for the Management of Pain, Agitation, Delirium, Immobility, and Sleep Disruption (PADIS) 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 PADIS 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 PADIS Guidelines that can be found on their website.
Commonly misunderstood aspects of the ABCDEFs are as follows:
- MYTH: The ABCDEFs and PADIS are advocating different things.
- TRUTH: These are similar constructs. As noted above, think of the ABCDEFs as a way of operationalizing the PADIS guidelines. There are many ways of going about this; the A2F 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 PADIS 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.
Wake Up and Breathe Flowchart
Spontaneous Awakening Trials (SATs) + Spontaneous Breathing Trials (SBTs)
Podcast - Audio Download
Wes Ely - Finding Out What Matters to Our PatientsMastering Intensive Care Podcast
- Part 1 - Genuine care and the ABCDEF
- Part 2 - Reading, communication and improving ourselves
- Part 3 - Balance, spiritual faith and end of life care
Caring for Critically Ill Patients with the ABCDEF Bundle: Results of the ICU Liberation Collaborative in Over 15,000 Adults.
Brenda T. Pun; Michele C. Balas; Mary Ann Barnes-Daly; Jennifer L. Thompson; J. Matthew Aldrich; Juliana Barr; Diane Byrum; Shannon S. Carson; John W. Devlin; Heidi J. Engel; Cheryl L. Esbrook; Ken D. Hargett; Lori Harmon; Christina Hielsberg; James C. Jackson; Tamra L. Kelly; Vishakha Kumar; Lawson Millner; Alexandra Morse; Christiane S. Perme; Patricia J. Posa; Kathleen A. Puntillo; William D. Schweickert; Joanna L. Stollings; Alai Tan; Lucy D’Agostino McGowan; E. Wesley Ely. Crit Care Med. 2018 Oct 18.
Critical Care Nurses’ Role in Implementing the ABCDEF Bundle
Balas MC et al., Crit Care Nurse. 2012
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
ICU Delirium Viewed Through the Lens of the PAD Guidelines and the ABCDEF Implementation Bundle
Critical Care Medicine 2015
Implementing the 2013 PAD guidelines: top ten points to consider.
Pun BT, Balas MC, Davidson J, Semin Respir Crit Care Med. 2013
Reducing iatrogenic risks: ICU-acquired delirium and weakness-crossing the quality chasm.
Vasilevskis EE et al. Chest. 2010
Sedation, Delirium and Mechanical Ventilation: the 'ABCDE' Approach
Morandi A, Brummel NE, Ely EW. Crit Care Med. 2011 Feb 17
The Science, Why, and What of ICU Liberation and the ABCDEF Bundle for Patients and Families
Dr. Wes Ely Hawaii SCCM 2017 Plenary