The ABCDEF bundle is gaining acceptance as an effective way to improve the care of critically ill patients, but some hospitals find implementation difficult. One hospital’s experience illustrates some of the challenges — and the strategies that can help overcome them.
The ABCDEF bundle is a resource from the Society of Critical Care Medicine that uses multiple assessments and strategies to reduce delirium and improve pain management for patients in intensive care. It also can improve long-term outcomes. The name is taken from the key components of the bundle: A — assess, prevent, and manage pain; B — both spontaneous awakening and spontaneous breathing trials; C — choice of analgesic and sedation; D — delirium: assess, prevent, and manage; E — early mobility and exercise; and F — family engagement and empowerment.
(Information on the ABCDEF bundle is available online at: https://bit.ly/2V001Wc. A Critical Care Nurse journal article on implementing the bundle is available online at: https://bit.ly/2HTClAA.)
Covers All ICU Patients
The bundle is different from some others in that it is not disease-specific, says Brenda T. Pun, DNP, RN, FCCM, program clinical manager for critical illness at the Brain Dysfunction and Survivorship Center at Vanderbilt University Medical Center in Nashville, TN. Vanderbilt has implemented the ABCDEF bundle with success.
“I often call it the wallpaper of the ICU. It should be visible in every patient’s room because it applies to everyone in the unit,” Pun says.
“It becomes this framework in which we can plug in any new recommendations or changes in the literature over time, keeping us all on the same page. It has many components that link together the many multidisciplinary players in an ICU — the nurse, doctor, respiratory therapists, social worker, physical therapist, pharmacist, family members.”
The bundle helps remind each participant of their teammates’ involvement and concerns, Pun says. It helps the team implement best practices outlined in other guides for ICU care, with each component standing alone but still interconnected with the others, she explains.
“For example, it’s really hard to mobilize a deeply sedated patient. If you’re only thinking about mobility and only implementing that component, disregarding pain, delirium, sedation levels, family presence, and the patient’s history of mobility, your efforts to implement the mobility component almost is set up for failure from the beginning,” Pun says.
“It’s not going to be sustainable with this patient or as a pattern within the unit. The bundle helps us to think about these things in concert, realizing that reducing sedation is a priority because it is so important for the patient to mobilize, not just because it is important for my patient to receive less sedative.”
Pun notes that any hospital can implement the ABCDEF bundle without any special resources. However, that doesn’t mean there are no challenges in implementation.
Pun recently was involved with research looking at the experience of many hospitals, and the first conclusion was that implementing the ABCDEF bundle improves outcomes, discharge rates, survival, use of physical restraints, and readmissions.
“It’s definitely doable, but it’s different for every unit implementing this bundle. It’s a different team and different resources, so that changes what is required to introduce this into your ICU culture and your workflow,” she says. “But the bundle can be used in any setting, with any type of hospital, and the question is just exactly how to merge this into your operations.”
EHR Can Be Problematic
Part of the challenge is that the ABCDEF bundle can seem like introducing six different programs at once, Pun explains. The biggest challenge, however, tends to be incorporating the bundle into the electronic health record.
“The use of this bundle highlights some problems in our big electronic record systems, the biggest being Epic and Cerner. Our charting, as professionals, is siloed in those systems, but the whole purpose of this bundle is to de-silo us so that we are communicating,” Pun says. “We quickly realized that a big barrier to tracking progress and facilitating communication is the way the electronic systems require us to chart in a very specific way so that nursing has no view of what respiratory therapy is charting, and they can’t see what nurses are charting.”
Pun and her colleagues have been working with the biggest EHR vendors to create dashboards that alleviate that problem, allowing team members to see what others are doing with each patient.
“Hospitals frequently complain that it is difficult to access the records to track their progress, much less use them in a meaningful way for daily clinical care,” Pun says.
“That was a huge hurdle for many of the sites where we studied use of this bundle. People were creating their own side versions in Excel to track progress and then try to export it in some way to create that communication link among team members.”
- Brenda T. Pun, DNP, RN, FCCM, Program Clinical Manager, Critical Illness, Brain Dysfunction and Survivorship Center, Vanderbilt University Medical Center, Nashville, TN. Phone: (919) 484-3964. Email: [email protected].
