Reducing Time on the Ventilator Using the ABCDEF Bundle

Teamwork is essential to improve patient care outcomes. This presentation will focus on a multidisciplinary initiative involving an internationally recognized bundle of interventions that reduce time on the ventilator for patients in the intensive care unit (ICU). The evidence-based bundle components target: Airway, Breathing, Coordination, Delirium, Exercise/Early mobility and Family involvement (ABCDEF). Airway strategies include a change to sub-glottic endotracheal tubes that reduce ventilator-associated pneumonia (VAP). Breathing strategies include reducing levels of sedation and scheduled spontaneous breathing trials to improve time to extubation. Coordination is by the bedside nurse so that an alert patient can pass a spontaneous breathing trial prior to extubation. Delirium prevention is a hallmark of this initiative. Patients who have less delirium have shorter lengths of stay and improved cognitive outcomes after ICU. Exercise and early mobility while on the ventilator only happen when patients are alert and delirium-free. Screening for delirium increased from 16% to 100% over a 1-year period. Family support was encouraged.

Multidisciplinary team strategies for enabling change over a one-year period were planned. The team audited current practice, provided staff education for all of the ABCDEF components, achieved administrative support for purchase of new equipment and increased support from Physical Therapy to help with early mobility.  The improved outcomes were publicized to all disciplines to maintain momentum, specifically to: nurses, respiratory therapists, rehabilitation specialists, pharmacists, physicians, administrators.

The team followed the principles of the Comprehensive Unit Safety Program (CUSP) to enact a permanent change in culture at the bedside. The status quo was having patients sedated and non-responsive. As a result of the ABCDEF initiative many more ventilated patients are alert, interactive and mobile. A strong motivator for this team was the realization that shorter lengths of stay in the ICU and freedom from delirium are both associated with improved patient outcomes post-ICU.