A Systemic Approach: ABCDEF Bundle

  • Matteo Manici
  • Alessandra Negro
  • Stefano Bambi


ABCDEF bundle is an evidence-based, integrated, systemic, and interdisciplinary approach to the management of mechanically ventilated patients. The acronym ABCDEF stands for the following: ABC, awake and breathing coordination; D, delirium monitoring; E, early mobility and exercise; and F, family involvement.

Spontaneous awakening and breathing trials have been combined into awake and breathing coordination, with the aim to reduce the duration of mechanical ventilation and ICU and hospital length of stay and improve the survival rates. Delirium monitoring improves the recognition of this disorder, but data on pharmacologic treatment are conflicting. Early mobility and exercise may reduce physical dysfunction and delirium rates. Family involvement in patients’ care can improve patient’s process of recovery.

Many institutions have implemented the concept of ABCDEF bundle through different practice guidelines. The main models are promoted by the American Association of Critical-Care Nurses (ACCN) and Society of Critical Care Medicine (SCCM).

In this chapter, the authors will propose a mixed model for the ABCDEF bundle implementation.


  1. 1.
    Resar R, Pronovost P, Haraden C, Simmonds T, Rainey T, Nolan T. Using a bundle approach to improve ventilator care processes and reduce ventilator-associated pneumonia. Jt Comm J Qual Patient Saf. 2005;31:243–8.CrossRefPubMedGoogle Scholar
  2. 2.
    Ely EW, Baker AM, Dunagan DP, Burke HL, Smith AC, Kelly PT, et al. Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously. N Engl J Med. 1996;335:1864–9. Scholar
  3. 3.
    Kress JP, Pohlman AS, O'Connor MF, Hall JB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med. 2000;342:1471–7. Scholar
  4. 4.
    Ely EW, Margolin R, Francis J, May L, Truman B, Dittus R, et al. Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Crit Care Med. 2001;29:1370–9.CrossRefPubMedGoogle Scholar
  5. 5.
    Jacobi J, Fraser GL, Coursin DB, Riker RR, Fontaine D, Wittbrodt ET, et al. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med. 2002;30:119–41.CrossRefPubMedGoogle Scholar
  6. 6.
    Ely EW, Shintani A, Truman B, Speroff T, Gordon SM, Harrell FE Jr, et al. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA. 2004;291:1753–62. Scholar
  7. 7.
    Breen D, Karabinis A, Malbrain M, Morais R, Albrecht S, Jarnvig IL, et al. Decreased duration of mechanical ventilation when comparing analgesia-based sedation using remifentanil with standard hypnotic-based sedation for up to 10 days in intensive care unit patients: a randomised trial. Crit Care. 2005;9:R200–10. Scholar
  8. 8.
    Chanques G, Jaber S, Barbotte E, Violet S, Sebbane M, Perrigault PF, et al. Impact of systematic evaluation of pain and agitation in an intensive care unit. Crit Care Med. 2006;34:1691–9. Scholar
  9. 9.
    Bailey P, Thomsen GE, Spuhler VJ, Blair R, Jewkes J, Bezdjian L, et al. Early activity is feasible and safe in respiratory failure patients. Crit Care Med. 2007;35:139–45. Scholar
  10. 10.
    Girard TD, Kress JP, Fuchs BD, Thomason JW, Schweickert WD, Pun BT, et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (awakening and breathing controlled trial): a randomised controlled trial. Lancet. 2008;371:126–34. Scholar
  11. 11.
    Morris PE, Goad A, Thompson C, Taylor K, Harry B, Passmore L, et al. Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med. 2008;36:2238–43. Scholar
  12. 12.
    Vasilevskis EE, Ely EW, Speroff T, Pun BT, Boehm L, Dittus RS. Reducing iatrogenic risks: ICU-acquired delirium and weakness--crossing the quality chasm. Chest. 2010;138:1224–33. Scholar
  13. 13.
    Girard TD, Jackson JC, Pandharipande PP, Pun BT, Thompson JL, Shintani AK, et al. Delirium as a predictor of long-term cognitive impairment in survivors of critical illness. Crit Care Med. 2010;38:1513–20. Scholar
  14. 14.
    Morandi A, Brummel NE, Ely EW. Sedation, delirium and mechanical ventilation: the 'ABCDE' approach. Curr Opin Crit Care. 2011;17:43–9. Scholar
  15. 15.
    Barr J, Fraser GL, Puntillo K, Ely EW, Gelinas C, Dasta JF, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41:263–306. Scholar
  16. 16.
    Trogrlić Z, Van der Jagt M, Bakker J, Balas MC, Ely EW, Van der Voort PHJ, et al. A systematic review of implementation strategies for assessment, prevention, and management of ICU delirium and their effect on clinical outcomes. Crit Care. 2015;19:157. Scholar
  17. 17.
    ACCN - American Association of Critical-Care Nursing. Implementing the ABCDE Bundle at the bedside. 2014. Accessed 16 Sep 2016.
  18. 18.
    SCCN - Society of Critical-Care Medicine. ABCDEF Bundle. 2015. Accessed on 16 Sep 2016.
  19. 19.
    Payen JF, Bosson JL, Chanques G, Mantz J, Labarere J, Investigators DOLOREA. Pain assessment is associated with decreased duration of mechanical ventilation in the intensive care unit: a post hoc analysis of the DOLOREA study. Anesthesiology. 2009;111:1308–16. Scholar
  20. 20.
    Vazquez M, Pardavila MI, Lucia M, Aguado Y, Margall MA, Asiain MC. Pain assessment in turning procedures for patients with invasive mechanical ventilation. Nurs Crit Care. 2011;16:178–85. Scholar
  21. 21.
    Reader T, Flin R, Lauche K, Cuthbertson BH. Non-technical skills in the intensive care unit. Br J Anaesth. 2006;96:551–9. Scholar
  22. 22.
    MacIntyre NR. Evidence-based assessments in the ventilator discontinuation process. Respir Care. 2012;57:1611–8. Scholar
  23. 23.
    Cabello B, Thille AW, Roche-Campo F, Brochard L, Gómez FJ, Mancebo J. Physiological comparison of three spontaneous breathing trials in difficult-to-wean patients. Intensive Care Med. 2010;36:1171–9. Scholar
  24. 24.
    Dietz AS, Pronovost PJ, Mendez-Tellez PA, Wyskiel R, Marsteller JA, Thompson DA, et al. A systematic review of teamwork in the intensive care unit: what do we know about teamwork, team tasks, and improvement strategies? J Crit Care. 2014;29:908–14. Scholar
  25. 25.
    Balas M, Buckingham R, Braley T, Saldi S, Vasilevskis EE. Extending the ABCDE bundle to the post-intensive care unit setting. J Gerontol Nurs. 2013;39:39–51. Scholar
  26. 26.
    Lane D, Ferri M, Lemaire J, McLaughlin K, Stelfox HT. A systematic review of evidence-informed practices for patient care rounds in the ICU*. Crit Care Med. 2013;41:2015–29. Scholar
  27. 27.
    Schweickert WD, Pohlman MC, Pohlman AS, Nigos C, Pawlik AJ, Esbrook CL, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet. 2009;373:1874–82. Scholar
  28. 28.
    Brummel NE, Girard TD. Preventing delirium in the intensive care unit. Crit Care Clin. 2013;29:51–65. Scholar
  29. 29.
    Adler J, Malone D. Early mobilization in the intensive care unit: a systematic review. Cardiopulm Phys Ther J. 2012;23:5–13.PubMedPubMedCentralGoogle Scholar
  30. 30.
    Desai SV, Law TJ, Needham DM. Long-term complications of critical care. Crit Care Med. 2011;39:371–9. Scholar
  31. 31.
    Hanekom S, Louw QA, Coetzee AR. Implementation of a protocol facilitates evidence-based physiotherapy practice in intensive care units. Physiotherapy. 2013;99:139–45. Scholar
  32. 32.
    Kayambu G, Boots R, Paratz J. Physical therapy for the critically ill in the ICU: a systematic review and meta-analysis. Crit Care Med. 2013;41:1543–54. Scholar
  33. 33.
    Leditschke IA, Green M, Irvine J, Bissett B, Mitchell IA. What are the barriers to mobilizing intensive care patients? Cardiopulm Phys Ther J. 2012;23:26–9.PubMedPubMedCentralGoogle Scholar
  34. 34.
    Li Z, Peng X, Zhu B, Zhang Y, Xi X. Active mobilization for mechanically ventilated patients: a systematic review. Arch Phys Med Rehabil. 2013;94:551–61. Scholar
  35. 35.
    Hodgson CL, Berney S, Harrold M, Saxena M, Bellomo R. Early patient mobilization in the ICU. Crit Care. 2013;17:207. Scholar
  36. 36.
    ACCN - American Association of Critical-Care Nursing. Family Presence: Visitation in the adult ICU. 2016. Accessed 16 Sep 2016.
  37. 37.
    McAdam JL, Arai S, Puntillo KA. Unrecognized contributions of families in the intensive care unit. Intensive Care Med. 2008;34:1097–101. Scholar
  38. 38.
    Balas MC, Vasilevskis EE, Olsen KM, Schmid KK, Shostrom V, Cohen MZ, et al. Effectiveness and safety of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle. Crit Care Med. 2014;42:1024–36. Scholar
  39. 39.
    Barnes-Daly MA, Phillips G, Ely EW. 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. 2017;45:171–8. Scholar
  40. 40.
    Ely EW. The ABCDEF bundle: science and philosophy of how ICU liberation serves patients and families. Crit Care Med. 2017;45:321–30. Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Matteo Manici
    • 1
  • Alessandra Negro
    • 2
    • 3
  • Stefano Bambi
    • 4
  1. 1.Anesthesia, Intensive Care and Hub Pain ServiceUniversity Hospital of ParmaParmaItaly
  2. 2.Vita-Salute San Raffaele UniversityMilanItaly
  3. 3.IRCCS San Raffaele HospitalMilanoItaly
  4. 4.Emergency & Trauma ICU, University Hospital CareggiFlorenceItaly

Personalised recommendations