Caring for Critically Ill Patients with the ABCDEF Bundle: Results of the ICU Liberation Collaborative in Over 15,000 Adults

Pun, Brenda T.; Balas, Michele C.; Barnes‐Daly, Mary Ann; Thompson, Jennifer L.; Aldrich, Janet; Barr, Juliana; Byrum, Diane; Carson, Shannon S.; Devlin, John W.; Engel, Heidi J.; Esbrook, Cheryl L.; Hargett, Ken; Harmon, Lori; Hielsberg, Christina; Jackson, James C.; Kelly, Tamra; Kumar, Vishakha; Millner, Lawson; Morse, Alexandra; Perme, Christiane; Posa, Patricia J.; Puntillo, Kathleen; Schweickert, William D.; Stollings, Joanna L.; Tan, Alai; McGowan, Lucy D’Agostino; Ely, E. Wesley

doi:10.1097/ccm.0000000000003482

Cited by 721 publications

(395 citation statements)

References 57 publications

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“…This interpretation was made because all the questions but one in the interview guide were specifically related to the experience of pain in the ICU and none mentioned any other discomfort. Nevertheless, to treat and assess pain is considered an important part of preventing hallucinations as a form of ICU delirium and as such is mentioned in the ABCDEF bundle for preventing delirium (Marra, Ely, Pandharipande, & Patel, 2017), where the effects have been seen in large populations (Pun et al, 2019). In the present study, the ABCDEF bundle was not implemented; therefore, the relationship between the pain and hallucinations reported could be of interest.…”

Section: Discussionmentioning

confidence: 93%

Patients´ experiences of pain in the intensive care – The delicate balance of control

Hylén

Åkerman

Idvall

et al. 2020

Journal of Advanced Nursing

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Aim To explore the patients´ experiences of pain when being cared for in the intensive care. Design An exploratory, qualitative design was chosen. Method Interviews were performed with patients (October 2015–March 2017) within a week of post‐intensive care (N = 16). Thematic analysis was used as method for analysis. Results The findings generated two themes – a lack of control and to struggle for control. Pain was described as overwhelming, both in body and mind and generating the experience of a lack of control, with feelings of incapacitation, isolation, and having their needs unmet. Feeling in control of the pain and thus in control of the situation was experienced as a constant struggle. Well‐planned care, finding ways to handle the pain and good communication were all helpful in this struggle. Conclusion The participants recalled their experience of pain in the ICU and control seems to be crucial for how pain is experienced. They experienced a lack of control due to not only the pain but also the treatment, which can be avoided by the nurse continuously evaluating and individualising the care. Balanced care, meeting the patients’ needs and good communication helps the patient feel more in control when experiencing pain. Impact The experience of pain is dependent on control for the intensive care patient. The nurse may help them gain control and thereby handle the experience of pain through including the patient, striving for better communication and implementing individualised care that continuously assesses and treats pain.

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Section: Discussionmentioning

confidence: 93%

Patients´ experiences of pain in the intensive care – The delicate balance of control

Hylén

Åkerman

Idvall

et al. 2020

Journal of Advanced Nursing

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“…We still lack a systematic approach to help manage the discomfort described by the patients. Jacobi et al (2002) Comfort has been reintroduced and human care added and visualised in the ICU in the eCASH model (Vincent et al, 2016) and the ABCDEF bundle, which specifically focuses on evaluating integrated, interprofessional approaches to symptom management during critical illness (Pun et al, 2019). These are examples of systematic approaches that are helpful and of great significance in succeeding with implementation projects.…”

Section: Discussionmentioning

confidence: 99%

“…To improve pain treatment and sedation in intensive care units (ICUs), both the establishment of a clinical practice based on these international recommendations and the monitoring of the adherence to evidencebased practice are important. Pun et al (2019) included 15,000 ICU patients in a study focused on evaluating the ABCDEF bundle approach (Assess, prevent, and manage pain; Both spontaneous awakening and breathing trials; Choice of analgesia and sedation; Delirium assessment, prevention and management; Early mobility and exercise; Family engagement/empowerment). The results of assessment using this ABCDEF bundle clearly showed how adherence to the recommended guidelines was associated with improved patient outcomes.…”

Section: Introductionmentioning

confidence: 99%

Movements and trends in intensive care pain treatment and sedation: What matters to the patient?

Wøien

2020

Journal of Clinical Nursing

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Background Oversedation, delirium and immobilisation in the intensive care unit are associated with increased length of stay in the unit. Routines of systematic pain and sedation assessment and the use of valid tools are highly stressed in international guidelines. For improving the quality of pain treatment and sedation in a Norwegian intensive care unit, in 2009–2015, we compared supplementation with an analgosedation approach and the existing systematic approach, measured by the adherence to current international pain, sedation and delirium guidelines. Methods In a longitudinal study following the Standards for Reporting Implementation Studies, pain, sedation, delirium and mobilisation data from patients' complete intensive care unit stays, encompassing three separate periods of 4–6 months, were compared. The primary outcome was adherence to current protocol including assessment and documentation of patients' level of pain, sedation and prevalence of delirium at least every 8 hr, early mobilisation and titration towards a light level of sedation. Results We included 205 patients, corresponding to 1,607 patient intensive care unit days. The patient sedation levels, measured by the Richmond Agitation and Sedation Scale, decreased significantly, from −2.2 in 2009–−1.7 in 2015, so did the amount of administrated propofol. Mean pain scores measured by the numeric rating scale during activity were maximum 3.1 in 2014, decreasing to 2.2 in 2015. In patients not able to self‐report, pain mean scores were 1.7 in 2014 and 1.6 in 2015, measured by the Critical Care Pain Observational Tool. The number of patients unable to assess for delirium decreased significantly. By discounting the group of patients unable to assess, the prevalence of delirium varied from 32%, 25% and 33%. Conclusion The goal of having an awake patient able to cooperate, with acceptable levels of pain, was gradually achieved during a 6‐year period. The results showed that pain treatment and sedation in the intensive care unit primarily succeeded in the setting of an established routine of systematic assessment and documentation. Relevance to clinical practice The results of the study draw attention to pain treatment, sedation and delirium in intensive care patients, as well as implementation strategies aimed at achieving healthcare personnel's adherence to international guidelines in clinical practice.

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“…Significant improvements in patient short and long term outcome can be achieved by implementing effective strategies to optimise pain management, reduce sedative exposure, and prevent and treat delirium in ICU patients [12,13]. The most effective measures for implementation are bundles and clinical concepts, such as the ABCDEF approach (Assess, prevent, and manage pain; Both spontaneous awakening and breathing trials: Choice of Analgesia and Sedation; Delirium assess, prevent, and manage; Early Mobility and Exercise; Family engagement/empowerment), which aims to improve the management of pain, sedation, and delirium [14].…”

Section: Introductionmentioning

confidence: 99%

Effects of pain, sedation and delirium monitoring on clinical and economic outcome: A retrospective study

et al. 2020

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Background Significant improvements in clinical outcome can be achieved by implementing effective strategies to optimise pain management, reduce sedative exposure, and prevent and treat delirium in ICU patients. One important strategy is the monitoring of pain, agitation and delirium (PAD bundle). We hypothesised that there is no sufficient financial benefit to implement a monitoring strategy in a Diagnosis Related Group (DRG)-based reimbursement system, therefore we expected better clinical and decreased economic outcome for monitored patients. Methods This is a retrospective observational study using routinely collected data. We used univariate and multiple linear analysis, machine-learning analysis and a novel correlation statistic (maximal information coefficient) to explore the association between monitoring adherence and resulting clinical and economic outcome. For univariate analysis we split patients in an adherence achieved and an adherence non-achieved group. Results In total 1,323 adult patients from two campuses of a German tertiary medical centre, who spent at least one day in the ICU between admission and discharge between 1. January 2016 and 31. December 2016. Adherence to PAD monitoring was associated with shorter hospital LoS (e.g. pain monitoring 13 vs. 10 days; p<0.001), ICU LoS, duration of mechanical ventilation shown by univariate analysis. Despite the improved clinical outcome, adherence to PAD elements was associated with a decreased case mix per day and profit per day

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Caring for Critically Ill Patients with the ABCDEF Bundle: Results of the ICU Liberation Collaborative in Over 15,000 Adults

Cited by 721 publications

References 57 publications

Patients´ experiences of pain in the intensive care – The delicate balance of control

Patients´ experiences of pain in the intensive care – The delicate balance of control

Movements and trends in intensive care pain treatment and sedation: What matters to the patient?

Effects of pain, sedation and delirium monitoring on clinical and economic outcome: A retrospective study

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