Implementation of the ABCDEF Bundle for Critically Ill ICU Patients During the COVID-19 Pandemic: A Multi-National 1-Day Point Prevalence Study

Keibun Liu; Kensuke Nakamura; Hajime Katsukawa; Peter Nydahl; Eugene Wesley Ely; Sapna R Kudchadkar; Kunihiko Takahashi; Muhammed Elhadi; Mohan Gurjar; Be Kim Leong; Chi Ryang Chung; Jayachandran Balachandran; Shigeaki Inoue; Alan Kawarai Lefor; Osamu Nishida

doi:10.3389/fmed.2021.735860

Implementation of the ABCDEF Bundle for Critically Ill ICU Patients During the COVID-19 Pandemic: A Multi-National 1-Day Point Prevalence Study

Front Med (Lausanne). 2021 Oct 28:8:735860. doi: 10.3389/fmed.2021.735860. eCollection 2021.

Authors

Keibun Liu¹, Kensuke Nakamura², Hajime Katsukawa³, Peter Nydahl⁴, Eugene Wesley Ely^{5

6}, Sapna R Kudchadkar^{7

8

9}, Kunihiko Takahashi¹⁰, Muhammed Elhadi¹¹, Mohan Gurjar¹², Be Kim Leong¹³, Chi Ryang Chung¹⁴, Jayachandran Balachandran¹⁵, Shigeaki Inoue^{16

17}, Alan Kawarai Lefor¹⁸, Osamu Nishida¹⁹

Affiliations

¹ Critical Care Research Group, Faculty of Medicine, The Prince Charles Hospital, University of Queensland, Brisbane, QLD, Australia.
² Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Hitachi, Japan.
³ Japanese Society for Early Mobilization, Tokyo, Japan.
⁴ Nursing Research, Department of Anesthesiology and Intensive Care Medicine, University Hospital of Schleswig-Holstein, Kiel, Germany.
⁵ Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University School of Medicine, Nashville, TN, United States.
⁶ Department of Veterans Affairs Medical Center, Geriatric Research Education and Clinical Center (GRECC), Tennessee Valley Healthcare System, Nashville, TN, United States.
⁷ Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
⁸ Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
⁹ Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
¹⁰ Department of Biostatistics, M&D Data Science Center, Tokyo Medical and Dental University, Tokyo, Japan.
¹¹ Faculty of Medicine, University of Tripoli, Tripoli, Libya.
¹² Department of Critical Care Medicine, Sanjay Gandhi Post Graduate Institute of Medical Sciences (SGPGIMS), Lucknow, India.
¹³ Department of Rehabilitation Medicine, Sarawak General Hospital, Kuching, Malaysia.
¹⁴ Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
¹⁵ Rehabilitation Department, Woodlands Health Campus, Yishun, Singapore.
¹⁶ Emergency and Critical Care Center, Kobe University Hospital, Kobe, Japan.
¹⁷ Department of Disaster and Emergency Medicine, Graduate School of Medicine, Kobe University, Kobe, Japan.
¹⁸ Department of Surgery, Jichi Medical University, Tochigi, Japan.
¹⁹ Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, Toyoake, Japan.

Abstract

Background: Data regarding delivery of evidence-based care to critically ill patients in Intensive Care Units (ICU) during the COVID-19 pandemic is crucial but lacking. This study aimed to evaluate the implementation rate of the ABCDEF bundle, which is a collection of six evidence-based ICU care initiatives which are strongly recommended to be incorporated into clinical practice, and ICU diaries for patients with and without COVID-19 infections in ICUs, and to analyze the impact of COVID-19 on implementation of each element of the bundle and independent associated factors. Methods: A world-wide 1-day point prevalence study investigated the delivery of the ABCDEF bundle and ICU diary to patients without or with COVID-19 infections on 27 January 2021 via an online questionnaire. Multivariable logistic regression analysis with adjustment for patient demographics evaluated the impact of COVID-19 and identified factors in ICU administrative structures and policies independently associated with delivery. Results: From 54 countries and 135 ICUs, 1,229 patients were eligible, and 607 (49%) had COVID-19 infections. Implementation rates were: entire bundle (without COVID-19: 0% and with COVID-19: 1%), Element A (regular pain assessment: 64 and 55%), Element B (both spontaneous awakening and breathing trials: 17 and 10%), Element C (regular sedation assessment: 45 and 61%), Element D (regular delirium assessment: 39 and 35%), Element E (exercise: 22 and 25%), Element F (family engagement/empowerment: 16 and 30%), and ICU diary (17 and 21%). The presence of COVID-19 was not associated with failure to implement individual elements. Independently associated factors for each element in common between the two groups included presence of a specific written protocol, application of a target/goal, and tele-ICU management. A lower income status country and a 3:1 nurse-patient ratio were significantly associated with non-implementation of elements A, C, and D, while a lower income status country was also associated with implementation of element F. Conclusions: Regardless of COVID-19 infection status, implementation rates for the ABCDEF bundle, for each element individually and an ICU diary were extremely low for patients without and with COVID-19 infections during the pandemic. Strategies to facilitate implementation of and adherence to the complete ABCDEF bundle should be optimized and addressed based on unit-specific barriers and facilitators.

Keywords: ABCDEF bundle; COVID-19; ICU diary; ICU liberation bundle; pandemic (COVID-19).