Being a critical care nurse is difficult. ICU nurses have high levels of emotional exhaustion and low personal accomplishment, with burnout having a huge impact on patients, staff and healthcare organizations. Nurses enter critical care to support patients during their most vulnerable times and to help achieve their optimal health goals. The Society of Critical Care Medicine (SCCM) ICU Liberation Bundle (A-F) is a toolkit to guide sedation and mobility practices organized in alphabetical order, often referred to as the ABCDEF bundle. The ABCDEF bundle supports nurses in accomplishing their mission of supporting optimal patient outcomes and having the satisfaction of helping their patients have the best outcomes.
The ABCDEF bundle can:
- Significantly decrease delirium and coma days
- Reduce the need for physical restraints
- Lower ICU admissions in half
- Achieve a 68% decrease in hospital deaths within seven days
In short, the bundle reduces critical care nurses’ workload and improves patient outcomes.
Awake and Walking ICU
I started my nursing career in an “Awake and Walking ICU,” where nearly all patients were awake soon after intubation; sedation was given only if there was an indication for sedation, and performing the highest level of mobility as early as appropriate was common. After a few years, I became a travel nurse and was shocked to find it was not standard practice at other healthcare organizations.
During this time, I started to experience burnout and considered leaving nursing. When I returned to work in an “Awake and Walking ICU” again, I realized that my job was far more fulfilling and sustainable. The differences in sedation management and early mobility practices, which decreased patient delirium and length of hospital stay, and increased patient participation in their care, supported me and my nursing career.
Delirium
Delirium is a life-threatening brain dysfunction that increases the psychological burden, risks, liabilities and staffing demands on nurses. Nurses report high levels of emotional stress, strain and burden when caring for patients with delirium.
Protecting and monitoring confused, scared, often combative and impulsive patients during hyperactive delirium is a major challenge for nurses. Hypoactive delirium can feel safer and easier to manage, but patients need increased support from nurses for turning, toileting, bathing and nutrition. Compounded by the responsibility of nurses maintaining patient safety with lines and tubes everywhere, patients are 11.6 times more likely to self-extubate when they have delirium. Delirium not only increases patient harm; it also may increase violence against nurses. Delirium severity is a predictor of nurse distress.
Delirium causes nurses to lose the opportunity of connection and communication with those they serve. Delirium contributes to difficulty interpreting patients’ needs and can increase nurse discomfort. Delirium increases time in the ICU an average of 4.47 days and 6.67 days in the hospital, and it doubles the nursing hours required for care.
ABCDEF Bundle
While delirium creates challenges, our critical care culture exacerbates these issues. Common practices of automatic sedation and immobility for ICU patients increases the risks of delirium. Sedation increases the risk of delirium and the severity of delirium. Contrary to popular belief, mechanical ventilation is not an independent indication for continuous sedation. Protocols such as the PADIS guideline lead ICU teams to aggressively avoid benzodiazepines and minimize sedatives such as propofol. Yet most ICUs routinely initiate continuous sedative drips after patients are intubated.
The ABCDEF bundle guides critical care teams to minimize sedation and provide prompt, early mobility. These interventions protect patients and nurses with the following tools and strategies:
- A: Assess, Prevent and Manage Pain
- B: Both Spontaneous Awakening Trials (SATs) and Spontaneous Breathing Trials (SBTs)
- C: Choice of Analgesia and Sedation
- D: Delirium: Assess, Prevent and Manage
- E: Early Mobility and Exercise
- F: Family Engagement and Empowerment
The objective of the ABCDEF bundle is to “produce patients who are more awake, cognitively engaged, and physically active … facilitate patient autonomy and the ability to express unmet physical, emotional, and spiritual needs.”
Mastery of the ABCDEF bundle leads to the creation of Awake and Walking ICUs. However, compliance with the bundle continues to be low in many ICUs, which perpetuates the burden on ICU nurses.
The ABCDEF bundle requires interdisciplinary teamwork from nursing, physical therapists, occupational therapists, medical providers and advanced practice nurses, pharmacy, respiratory therapists and others. It is also important to engage the patient’s family and other loved ones to foster a comprehensive and patient-centered approach.
The ABCDEF bundle requires true collaboration, skilled communication and other AACN Healthy Work Environment standards. By mastering this bundle, you may see improvements in the workplace environment. Nurses can be key leaders in ensuring bundle compliance and interdisciplinary collaboration through tools and processes such as an RN rounding tool.
Through interdisciplinary collaboration early in the ICU admission process, patients can remain awake and mobile, potentially staying cognitively and physically intact so they can be more engaged in their care. Ultimately, less staff and equipment are required for mobility as patients preserve their muscle mass and function at higher rates. They are liberated from the ventilator and transferred out of the ICU far sooner.
ABCDEF Bundle, Appropriate Staffing and Cost of Care
Appropriate critical care staffing is key to practice the ABCDEF bundle effectively. Boehm and team found that increased workload burden for intensive care providers decreased adherence to the ABCDEF bundle. Further, not implementing this bundle puts more strain on staff through increased time on the ventilator, time in the hospital, staff to care for patients, readmissions to the ICU and hospital, healthcare costs and, ultimately, nurse burnout.
The ABCDEF bundle is one of the most effective ways to advocate for appropriate staffing standards in critical care. There is also a major business case for the ABCDEF bundle. Delirium increases hospitalization costs by 39%. The ABCDEF bundle can decrease healthcare costs by at least 30%. A nurse-led early mobility initiative in a medical ICU in New York resulted in a 57% decrease in mortality and a 33% decrease in time on the ventilator, and was projected to have saved $2,070,000 that year. Another ICU in Georgia found their nursing-led mobility initiative increased mobility by 43% and resulted in a 50%-100% decrease in hospital-acquired complications. A nurse-led ABCDEF bundle initiative in an ICU in Massachusetts resulted in a 1.2 day decrease in time on the ventilator and $76,100 in cost savings, with a projected annual fiscal savings of $304,400. All of those costs saved is money in the bank because of the ABCDEF bundle.
ABCDEF Bundle Mitigates Nurse Burnout
Common sedation and immobility practices cause increased burden for nurses, and most of us probably don’t make that connection. These practices feel normal, familiar and accepted as part of the care process. During our continuing nurse staffing crisis, many nurses are just trying to make sure we and our patients survive each shift. Unfortunately, the practices we use just to survive are causing increased stress and work for nurses - increasing burnout - and poor outcomes for patients.
Nurses who know the harm of sedation and immobility but lack support or resources face moral distress and injury when they are unable to provide optimal evidence-based care for their patients. They are forced to witness and struggle to treat patients with the often preventable harm of delirium. When nurses know the lifelong negative impacts and increased mortality that survivors will face from these conditions, they are often left in ethical turmoil.
There is a solution!
Turning to evidence-based sedation and mobility practices can lead to improved outcomes for nurses and patients. We must support nurses to not just know about the ABCDEF bundle, but to truly master it so they can support optimal patient outcomes, maintain the nurse-patient human connection and mitigate burnout.
How would awake, oriented and mobile patients affect your burnout and workload in the ICU?
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