What’s New in the Patient Safety World

December 2010

The ABCDE Bundle



Despite this month’s column “Bad Bundle? Or Not?”, we still like bundles. And there is a new bundle being promoted, the “ABCDE bundle” (Vasilevskis 2010). This really focuses on prevention of two very common and very serious iatrogenic problems seen in our ICU’s: delirium and ICU-acquired weakness. The ABCDE acronym stands for “Awakening and Breathing Coordination”, “Delirium monitoring”, and “Exercise/Early mobility”.


ICU delirium and ICU-acquired weakness are associated with significant morbidity and mortality, excessive lengths of ICU and hospital stay, and excessive costs. Both are potentially preventable. The authors of the paper describe the risk factors and contributing factors for both complications and suggest the ABCDE bundle as a way to reduce the risk of patients developing either or both complications. The individual components of the bundle are well-accepted interventions in most ICU’s.


Awakening the patient daily is the first component. Daily sedation “vacations” are a key component of the IHI VAP Bundle and other bundles designed to prevent ventilator-associated pneumonia. Minimizing sedation also helps reduce the incidence of delirium in the intubated, mechanically-ventilated patient. We all recognize there is a tendency to oversedate ICU patients on ventilators. We even reported in our March 2010 What’s New in the Patient Safety World column “If Sedation Vacations Work, Why Not Eliminate Sedation All Together?” a study by a group of Danish clinical researchers (Strem 2010) who did a randomized controlled trial in which ICU patients on mechanical ventilation were randomized to receive either no sedation or daily interrupted sedation. They found that patients who received no sedation had significantly fewer days on ventilators, shorter ICU stays, and shorter total hospital LOS. There was no difference in accidental extubations or VAP, though more patients in the no sedation group had agitated delirium.


The B component Breathing refers to daily interruptions of mechanical ventilation. The authors stress that use of protocolized management by nonphysicians in the ICU have been shown to be safe and effective.


The C component is Coordination of daily awakening and daily breathing. Coordinating these two interventions has been shown to produce better outcomes than either intervention alone. The ABC trial (Awakening and Breathing Controlled trial) (Girard et al 2008), which we discussed in our June 23, 2009 Patient Safety Tip of the Week “More on Delirium in the ICU” was a multicenter prospective controlled trial that paired the use of spontaneous breathing trials (SBT’s) with spontaneous awakening trials (SAT’s) in comparison to a usual care group in mechanically ventilated ICU patients. Results demonstrated patients in the intervention group had more ventilator-free days, shorter ICU and total hospital lengths of stay, and a 32% better survival at one year.


The D component, Delirium monitoring, has been the topic of many of our own columns. They discuss many of the validated tools, such as the CAM-ICU and the Intensive Care Delirium Screening Checklist, plus sedation scales like the Richmond Agitation-Sedation Score (RASS) and how these objective measures lead to reduction in complications.


The E component, Exercise/Early Mobility is based in multiple studies that have demonstrated early mobilization and early physical therapy contributing to improved outcomes in mechanically ventilated ICU patients.


They then go on to provide statistics about the relative frequency (actually infrequency is the better term!) each of these components is used in typical ICU care and gaps that exist between evidence-based principles and actual clinical care. Their section on using members of the entire ICU team, interdisciplinary care, and good communication are critical in developing a culture of safety in the ICU. They also note use of some of our other favorite tools, checklists and ICU daily goals, are helpful during implementation of the ABCDE bundle.


This is a very good paper posing use of a very logical bundle. Getting some actual outcome measurements after implementation of the full ABCDE bundle should further solidify more widespread use of this bundle. The paper also has excellent references to the individual components of the bundle.



Update: See also our February 2013 What's New in the Patient Safety World column “The ABCDE Bundle in Action” and our September 20, 2016 Patient Safety Tip of the Week “Downloadable ABCDEF Bundle Toolkits for Delirium”.







Eduard E. Vasilevskis EE, Ely EW,  Speroff T, et al. Reducing Iatrogenic Risks: ICU-Acquired Delirium and Weakness—Crossing the Quality Chasm. Chest 2010; 138: 1224-1233   November 2010




Strem T, Martinussen T, Toft P. A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial. The Lancet 2010; 375: 475 - 480




Girard TD, Kress JP, Fuchs BD, 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. The Lancet 2008; 371: 126 - 134, 12 January 2008















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