What to Ask Your Doctor
When a loved one is admitted to the ICU, the family suffers a great deal because of both the difficulty in seeing what their loved one is going through but also because of the “uncertainty of not knowing.” It is this latter part that often times the patient herself or himself is spared from via the advent of receiving pain medications and sedatives that can make them unaware of what is going on and less likely to ponder the upcoming days’ events. The family, however, is acutely aware of the massive number of things happening and yet at the same time confused by the steps being taken by the ICU team to monitor and care for their loved one. This page is all about those items and created to help you understand key components of ICU care which are often "bundled" into a series of steps taken, every day, to ensure that your loved one is as comfortable as possible, as safe as possible, and avoiding any iatrogenic harm (that means harm that can be caused by the care they are receiving).
While different ICUs can organize their care in very different ways, there are many ICUs that are implementing the most widely used set of clinical care guidelines based on the most recent evidence of “best care.” Those guidelines are called the PADIS (Pain, Agitation, Delirium, Illness, and Sleep Disruption) Guidelines published by the Society of Critical Care Medicine (SCCM), or the SCCM’s PADIS Guidelines. These guidelines are always in the process of being updated as new data emerge, and it is important to stress that just because guidelines are published doesn’t meant that your doctor or ICU team agrees with all elements of those guidelines. We mention this to avoid you reading something here that your team may not be doing or may disagree with, and we endorse the importance of local physicians within your institution having the autonomy to do what they believe is right for your loved one even it that is counter to the guidelines, because they know their patient best and because no set of guidelines should be applied as a “one shoe fits all” set of rules.
Having said that, there are some extremely robust and highly well-conducted studies that have taught us numerous ways of improving ICU care over the past two decades, and those studies have been logically assembled into a set of steps now known as the ABCDEF (A2F) Bundle. The first 5 letters of the bundle represent the actual “medical monitoring and interventions” while the last letter introduced the most important member of the ICU team – the Family, which obviously includes the main person on the team, the PATIENT. These steps are outlined in-depth on the medical professional portal of this same website, and here we are only making sure that you understand the basic concepts behind this bundle of care that your loved one is going to be receiving.
Every medical center wants to have highly functioning ICU interdisciplinary teams that partner with patients and families to create a safe and comfortable patient environment. To do this, one route supported by the most up-to-date medical science, is to implement the PADIS guidelines, and one way to get those guidelines implemented with success is to use the A2F bundle. Many ICUs are now measuring teamwork by how well and how consistently they coordinate the steps of this entire bundle:
What are the components of the A2F bundle?
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 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.