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?

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We 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 determine whether higher Awakening and Breathing Coordination, Choice of drugs, Delirium monitoring and management, Early mobility, and Family engagement (ABCDEF) bundle compliance 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 analysis of patients with and without mechanical ventilation. What percentage 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 Guidelines 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 provision of information regarding the frequency of patient pain assessment, the prevalence of pain not controlled with fentanyl, and medication duration and average daily dose of fentanyl 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 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 element 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 settings. However, we could not determine if considering each element 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.

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