ABCDEF ICU Bundle of Care - Interview with Michele Balas


  • Trauma Columnist
    Specializes in Nephrology, Cardiology, ER, ICU. Has 31 years experience.

Best practices for ICU patients involves a collaboration of disciplines. This includes physicians, nurses, respiratory therapists, other therapists as well as many ancillary personnel. The goal is to get the patient well enough to get discharged from the ICU.

A recommendation of best practices from the Society of Critical Care Medicine. It consists of:

A - Assess, Prevent and Manage Pain

  • Compare valid and reliable pain assessment tools.
  • Identify special challenges to effective pain assessment, prevention, and management.
  • Integrate effective strategies to prevent and manage pain into everyday clinical practice.

B - Both SBT and SAT. Spontaneous breathing trials (SBT) and spontaneous awakening trials

  • Studies have shown that using SAT and SBT synergistically helps decrease mechanical ventilation days, hospital lengths of stay and delirium.
  • Focuses on setting a time(s) each day to stop sedative medications, orient the patient to time and day, and conduct an SBT in an effort to liberate the patient from the ventilator.

C - Choice of Analgesia and Sedation

  • Focuses on constructing a safe and effective medication regimen for the management of pain and agitation in critically ill adults, consistent with ICU pain, agitation and delirium (PAD). Guidelines recommendations:
  • Treat pain first before considering sedative therapy.
  • Not all mechanically ventilated ICU patients need to be started on IV opioid and/or sedation infusions following intubation.
  • Use IV bolus doses liberally before starting or increasing opioid or sedative IV infusion

D - Delirium; Assess, Prevent and Manage

  • Delirium is experienced by 50%–80% of mechanically ventilated patients and 20%–50% of patients with illness of lower severity
  • Results in prolonged hospitalization increased mortality and increased cost
  • Long-term effects on the patient include an increased risk of mortality and long-term cognitive impairment.

E - Early Mobility and Exercise

  • The key question to ask during rounds is: Did the patient achieve maximum mobility or exercise today?
  • Was the patient walking before admission?
  • Is the patient hemodynamically stable?
  • Is the patient awake?

F -Family Engagement and Empowerment

  • Keeping patients and families informed
  • Actively involving patients and families in decision-making
  • Actively involving patients and families in self-management
  • Providing both physical comfort and emotional support to patients and families
  • Maintaining a clear understanding of patients' concepts of illness and cultural beliefs

Mary Watts, BSN, RN,'s Content and Community Director recently met with Michele Balas, PhD, RN, CCRN, FAAN to discuss the ABCDEF bundle of care practices in the ICU.

They discussed delirium as a syndrome that ICU caregivers used to think as "the patients are old, they get confused and it will get better by the time they go home.” This confusion is really a consequential experience. Having an episode of delirium in the ICU can cause cognitive changes even after patients are discharged home. "We now know that some common practices can cause more problems.”

For instance, it is not always necessary to include benzodiazepines as part of a sedative cocktail. The use of some drugs can cause a lot of functional decline and they are also associated with problems with memory later on. Dr. Balas went on to state, "ICU care is focused on how to keep patients alive but we must also recognize how pts interact once they leave the hospital.”

She emphasized that the ABCDEF bundle developed in stages:

  • In the 1990's - studies showed low tidal volumes helped to facilitate extubation, so they started daily weaning trials
  • Pioneers in this field developed SBT (spontaneous breathing trials) and patients were off the ventilator sooner. These pts had better outcomes.
  • The next stage was turning off the ventilator as well as sedation - these patients had even more improved outcomes

Nurses were at the forefront of implementing the ABCDEF bundle and as continued studies are conducted, patient care will also continue to improve.


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This is great information. Very encouraging. The interview was well worth watching. Thank you.

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