Online Letters to the Editor
To What Extent Does ABCDEF Bundle
Improve Hospital Survival and Reduce Brain
Dysfunction of 1,438 Patients With Mechanical
Ventilation in Seven California Community
Hospitals?
To the Editor:
W
e read with great interest the article published in
a recent issue of Critical Care Medicine by Barnes-
Daly et al (1) and appreciate their efforts to deter-
mine whether higher Awakening and Breathing Coordination,
Choice of drugs, Delirium monitoring and management, Early
mobility, and Family engagement (ABCDEF) bundle compli-
ance was independently associated with improved survival and
more days free of delirium and coma. However, we would like
to highlight four concerns regarding this work.
First, the ratio of participants with any mechanical ventilation
was only 23.7%. In a landmark study showing the effectiveness
and safety of the ABCDE bundle, Balas et al (2) examined 296
patients, including 187 mechanically ventilated patients (63.2%).
In this study, elements A, B, C1, and C2 of the bundle were not
applicable to patients not undergoing mechanical ventilation. As
shown in supplemental Table 4, the compliance with elements D
and E was almost 100%, whereas the compliance with elements
A, B, C1, and C2 ranged 69.5–87.6%. Initially, the evidence-based
ABCDE bundle was an integrated and interdisciplinary approach
to the management of mechanically ventilated patients (3). Thus,
we are interested in additional information on the subgroup analy-
sis of patients with and without mechanical ventilation. What per-
centage of increased odds of hospital survival and more days free
of delirium and coma do the patients with mechanical ventilation
have for every 10% increase in total and partial bundle compliance?
Second, element A has been revised in ICU Liberation, and
element A is “Assess, Prevent, and Manage Pain” (4). In this
study, only element C2 consisted of Clinical Practice Guide-
lines for the “Management of Pain, Agitation, and Delirium in
Adult Patients in the Intensive Care Unit” guidelines (5) for
sedation as avoidance of analgosedation (pain-first approach).
The pain control goal was 0–2/8 of the Numerical Rating Scale
and 0–3 of the Critical-Care Pain Observation Tool. The pro-
vision of information regarding the frequency of patient pain
assessment, the prevalence of pain not controlled with fen-
tanyl, and medication duration and average daily dose of fen-
tanyl might help readers to understand the results better.
Third, there was no information regarding compliance
with element F. The author mentioned in the study procedures
that compliance with element F was met if the patient/family
had participated in rounds or a family conference had been
Copyright © 2017 by the Society of Critical Care Medicine and Wolters
Kluwer Health, Inc. All Rights Reserved.
Critical Care Medicine www.ccmjournal.org e617
held. We are also interested in understanding the frequency
of rounds or conferences with the family, and efforts to gain
maximum benefits of family presence and flexible visitation in
these seven California community hospitals. Such information
would help clinicians to understand better the practice of ele-
ment F for ICU patients and their family.
Finally, this study clarifies the benefits of partial compliance
with the ABCDEF bundle, which may be useful in clinical set-
tings. However, we could not determine if considering each ele-
ment of the ABCDEF bundle to have the same effect on the
improvement of hospital survival rates and reduction in brain
dysfunction was appropriate. To improve clinical practice in the
ICU, we should prioritize the elements of the ABCDEF bundle
according to the benefits of compliance with each element.
The authors have disclosed that they do not have any poten-
tial conflicts of interest.
Shunsuke Taito, PhD, Division of Rehabilitation, Department
of Clinical Practice and Support, Hiroshima University
Hospital, Minami-ku, Hiroshima, Japan; Hideto Yasuda, MD,
Department of Intensive Care Medicine, Kameda Medical
Center, Kamogawa, Chiba, Japan
REFERENCES
1. Barnes-Daly MA, Phillips G, Ely EW: Improving Hospital Survival
and Reducing Brain Dysfunction at Seven California Community
Hospitals: Implementing PAD Guidelines Via the ABCDE Bundle in
6,064 Patients. Crit Care Med 2017; 45:171–178
2. Balas MC, Vasilevskis EE, Olsen KM, et al: Effectiveness and safety
of the awakening and breathing coordination, delirium monitoring/
management, and early exercise/mobility bundle. Crit Care Med
2014; 42:1024–1036
3. Morandi A, Brummel NE, Ely EW: Sedation, delirium and mechani-
cal ventilation: The ‘ABCDE’ approach. Curr Opin Crit Care 2011;
17:43–49
4. ICU Liberation: ABCDEF Bundles. Available at: http://www.iculibera-
tion.org. Accessed November 24, 2016
5. Barr J, Fraser GL, Puntillo K, et al; American College of Critical Care
Medicine: 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
DOI: 10.1097/CCM.0000000000002339
The authors reply:
W
e thank the authors (1) for their critical appraisal
of our data (2) from seven California community
hospitals describing a dose-response relationship
between Awakening and Breathing Coordination, Choice of
drugs, Delirium monitoring and management, Early mobility,
and Family engagement (ABCDEF) bundle compliance and
reductions in delirium/coma and improvements in survival
even after adjusting for relevant covariates.
The authors questioned the magnitude of data for ventilated
versus nonventilated patients. Importantly, evidence has accrued