The pharmacist’s role in implementation of the ABCDEF bundle into clinical practice

Abstract

Purpose To summarize published data regarding implementation of the ABCDEF bundle, a multicomponent process for avoidance of oversedation and prolonged ventilation in intensive care unit (ICU) patients; discuss pertinent literature to support each bundle element; and discuss the role of the pharmacist in coordinating bundle elements and implementation of the ABCDEF bundle into clinical practice. Summary Neuromuscular weakness and ICU-acquired weakness are common among critically ill patients and associated with significant cost and societal burdens. Recent literature supporting early liberation from mechanical ventilation and early mobilization has demonstrated improved short- and long-term outcomes. With expanded use of pharmacy services in the ICU setting, pharmacists are well positioned to advocate for best care practices in ICUs. A dedicated, interprofessional team is necessary for the implementation of the ABCDEF bundle in inpatient clinical practice settings. As evidenced by a number of studies, successful implementation of the ABCDEF bundle derives from involvement by motivated and highly trained individuals, timely completion of individual patient care tasks, and effective leadership to ensure proper implementation and ongoing support. Factors commonly identified by clinicians as barriers to bundle implementation in clinical practice include patient instability and safety concerns, lack of knowledge, staff concerns, unclear protocol criteria, and lack of interprofessional team care coordination. This narrative review discusses research on bundle elements and recommendations for application by pharmacists in clinical practice. Conclusions Despite the benefits associated with implementation of the ABCDEF bundle, evidence suggests that the recommended interventions may not be routinely used within the ICU. The pharmacist provides the expertise and knowledge for adoption of the bundle into everyday clinical practice.

Part II: Case series: Acute agitation, delirium, and sleep management

“…78 Many bundle elements are medication related, highlighting the critical role that the pharmacist has in implementing and ensuring daily incorporation into patient care. 79 Pharmacologic therapies targeted at preventing delirium in critically ill patients are not recommended. The therapies that have been studied to prevent ICU delirium and failed to show benefits in clinical outcomes include haloperidol, atypical antipsychotics, dexmedetomidine, statins, and ketamine.…”

Critical care pharmacy: Our next 30 years

“…While important studies highlight the value of pharmacists in the direct patient care realm (e.g., attending interprofessional rounds reduced adverse drug events by 70% 3,30 ), similarly important studies show improvements in ICU length of stay through pharmacist developed and run quality improvement protocols. [31][32][33] Finally, professional service (e.g., education, research, organizational involvement) is an oft-overlooked (and understudied) but key component to how pharmacists improve outcomes.…”

Postacute coronavirus disease‐2019 syndrome: Review of the literature and role of the pharmacist

“…Monitoring of hemodynamics is important with dexmedetomidine and propofol with the tendency to cause hypotension and bradycardia to varying degrees. Propofol will achieve deeper sedation goals compared with dexmedetomidine, but dexmedetomidine may facilitate weaning of mechanical intubation; a clinical pharmacist is equipped with these considerations and can contribute to the multidisciplinary discussion 54,55 …”