Implementing the ABCDEF Bundle: Top 8 Questions Asked During the ICU Liberation ABCDEF Bundle Improvement Collaborative

Barriers to Implementing the ICU Liberation Bundle in a Single-center Pediatric and Cardiac ICUs

Objectives: The intensive care unit (ICU) Liberation "ABCDEF" Bundle improves outcomes in critically ill adults. We aimed to identify common barriers to Pediatric ICU Liberation Bundle element implementation, to describe differences in barrier perception by ICU staff role, and to describe changes in reported barriers over time. Study Design: A 91-item survey was developed based on existing literature, iteratively revised, and tested by the PICU Liberation Committee at Seattle Children's Hospital, a tertiary free-standing academic children's hospital. Voluntary surveys were administered electronically to all ICU staff twice over 4-week periods in 2017 and 2020. Survey Respondents: 119 (2017) and 163 (2020) pediatric and cardiac ICU staff, including nurses (n = 142, 50%), respiratory therapists (RTs) (n = 46, 16%), attending and fellow physicians, hospitalists, and advanced practice providers (APPs) (n = 62, 22%), physical, occupational, and speech-language pathology therapists (n = 25, 9%), and pharmacists (n = 7, 2%). Measurements and Main Results: Respondents widely agreed that increased workload (78%-100% across roles), communication (53%-84%), and lack of RT-directed ventilator weaning (68%-88%) are barriers to implementation. Other barriers differed by role. In 2020, nurses reported liability (59%) and personal injury (68%) concerns, patient severity of illness (24%), and family discomfort with ICU liberation practices (41%) more frequently than physicians and APPs (16%, 6%, 8%, and 19%, respectively; P < .01 for all). Between 2017 and 2020, some barriers changed: RTs endorsed discomfort with early mobilization less frequently (50% vs 11%, P = .028) and nurses reported concern for patient harm less frequently (51% vs 24%, P = .004). Conclusions: Implementation efforts aimed at addressing known barriers, including educating staff on the safety of early mobility, considering respiratory therapist-directed ventilator weaning, and standardizing interdisciplinary discussion of Pediatric ICU Liberation Bundle elements, will be needed to overcome barriers and improve ICU Liberation Bundle implementation.

Improving Outcomes in Mechanically Ventilated Adult ICU Patients Following Implementation of the ICU Liberation (ABCDEF) Bundle Across a Large Healthcare System

OBJECTIVES

To measure how the ICU Liberation Bundle (aka ABCDEF Bundle or the Bundle) affected clinical outcomes in mechanically ventilated (MV) adult ICU patients, as well as bundle sustainability and spread across a healthcare system.

DESIGN

We conducted a multicenter, prospective, cohort observational study to measure bundle performance versus patient outcomes and sustainability in 11 adult ICUs at six community hospitals. We then prospectively measured bundle spread and performance across the other 28 hospitals of the healthcare system.

SETTING

A large community-based healthcare system.

PATIENTS

In 11 study ICUs, we enrolled 1,914 MV patients (baseline n = 925, bundle performance/outcomes n = 989), 3,019 non-MV patients (baseline n = 1,323, bundle performance/outcomes n = 1,696), and 2,332 MV patients (bundle sustainability). We enrolled 9,717 MV ICU patients in the other 28 hospitals to assess bundle spread.

INTERVENTIONS

We used evidence-based strategies to implement the bundle in all 34 hospitals.

MEASUREMENTS AND MAIN RESULTS

We compared outcomes for the 12-month baseline and bundle performance periods. Bundle implementation reduced ICU length of stay (LOS) by 0.5 days (p = 0.02), MV duration by 0.6 days (p = 0.01), and ICU LOS greater than or equal to 7 days by 18.1% (p < 0.01). Performance period bundle compliance was compared with the preceding 3-month baseline compliance period. Compliance with pain management and spontaneous awakening trial (SAT) and spontaneous breathing trial (SBT) remained high, and reintubation rates remained low. Sedation assessments increased (p < 0.01) and benzodiazepine sedation use decreased (p < 0.01). Delirium assessments increased (p = 0.02) and delirium prevalence decreased (p = 0.02). Patient mobilization and ICU family engagement did not significantly improve. Bundle element sustainability varied. SAT/SBT compliance dropped by nearly half, benzodiazepine use remained low, sedation and delirium monitoring and management remained high, and patient mobility and family engagement remained low. Bundle compliance in ICUs across the healthcare system exceeded that of study ICUs.

CONCLUSIONS

The ICU Liberation Bundle improves outcomes in MV adult ICU patients. Evidence-based implementation strategies improve bundle performance, spread, and sustainability across large healthcare systems.

Ethisch begründet entscheiden in der Intensivmedizin

The process recommendations of the Ethics Section of the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI) for ethically based decision-making in intensive care medicine are intended to create the framework for a structured procedure for seriously ill patients in intensive care. The processes require appropriate structures, e.g., for effective communication within the treatment team, with patients and relatives, legal representatives, as well as the availability of palliative medical expertise, ethical advisory committees and integrated psychosocial and spiritual care services. If the necessary competences and structures are not available in a facility, they can be consulted externally or by telemedicine if necessary. The present recommendations are based on an expert consensus and are not the result of a systematic review or a meta-analysis.

The Intensive Care Unit Bundle Board: A Novel Real-Time Data Visualization Tool to Improve Maintenance Care for Invasive Catheters

BACKGROUND

Critically ill patients are at greater risk of healthcare-associated infections (HAIs). The use of maintenance bundles helps to reduce this risk but also generates a rapid accumulation of complex data that is difficult to aggregate and subsequently act upon.

OBJECTIVES

We hypothesized that a digital display summarizing nursing documentation of invasive catheters (including central venous access devices, arterial catheters, and urinary catheters) would improve invasive device maintenance care and documentation. Our secondary objectives were to see if this summary would reduce the duration of problematic conditions, that is, characteristics associated with increased risk of infection.

METHODS

We developed and implemented a data visualization tool called the "Bundle Board" to display nursing observations on invasive devices. The intervention was studied in a 28-bed medical intensive care unit (MICU). The Bundle Board was piloted for 6 weeks in June 2022 and followed by a comparison phase, where one MICU had Bundle Board access and another MICU at the same center did not. We retrospectively applied tile color coding logic to prior nursing documentation from 2021 until the pilot phase to facilitate comparison pre- and post-Bundle Board release.

RESULTS

After adjusting for time, other quality improvement efforts, and nursing shift, multiple linear regression demonstrated a statistically significant improvement in the completion of catheter care and documentation during the pilot phase (p < 0.0001) and comparison phase (p = 0.002). The median duration of documented problematic conditions was significantly reduced during the pilot phase (p < 0.0001) and in the MICU with the Bundle Board (comparison phase, p = 0.027).

CONCLUSION

We successfully developed a data visualization tool that changed ICU provider behavior, resulting in increased completion and documentation of maintenance care and reduced duration of problematic conditions for invasive catheters in MICU patients.

Intensive Care Unit Diaries: A Nurse-Led Program

BACKGROUND

Following intensive care unit stays, patients with post-intensive care syndrome can experience mental health symptoms that impact quality of life. Intensive care unit diaries have been shown to improve outcomes for patients and their families.

LOCAL PROBLEM

Identification of limited support for high volumes of intensive care unit patients and families led to implementation of an intensive care unit diary program in a 24-bed adult medical-surgical intensive care unit.

METHODS

Patients requiring mechanical ventilation with an expected intensive care unit stay of more than 24 hours were provided intensive care unit diaries. Nursing staff and patients' families entered daily descriptive narratives of patients' progress during the stay. After intensive care unit discharge, patients and families reviewed the diaries to improve acceptance of their intensive care unit experience. Project evaluation included review of patient and family follow-up calls, a staff nurse feedback survey, and project champion debriefing sessions to gauge implementation success and feasibility.

RESULTS

Twenty diaries were completed and distributed to patients or families at intensive care unit discharge. Follow-up calls illustrated support and gratitude for diaries regardless of patient outcomes. Patients reported that diaries helped fill memory gaps between intensive care unit admission and discharge. Nurse surveys and project champion debriefings confirmed that completion of intensive care unit diary entries had minimal impact on workload, eased communication, and improved staff members' coping skills.

CONCLUSION

Successful intensive care unit diary program implementation has the potential to benefit patients, families, and nursing staff for little organizational cost.

Effects of a National Quality Improvement Collaborative on ABCDEF Bundle Implementation

BACKGROUND

The ABCDEF bundle (Assess, prevent, and manage pain and Delirium; Both spontaneous awakening and breathing trials; Choice of analgesia/sedation; Early mobility; and Family engagement) improves intensive care unit outcomes, but adoption into practice is poor.

OBJECTIVE

To assess the effect of quality improvement collaborative participation on ABCDEF bundle performance.

METHODS

This interrupted time series analysis included 20 months of bundle performance data from 15 226 adults admitted to 68 US intensive care units. Segmented regression models were used to quantify complete and individual bundle element performance changes over time and compare performance patterns before (6 months) and after (14 months) collaborative initiation.

RESULTS

Complete bundle performance rates were very low at baseline (<4%) but increased to 12% by the end. Complete bundle performance increased by 2 percentage points (SE, 0.9; P = .06) immediately after collaborative initiation. Each subsequent month was associated with an increase of 0.6 percentage points (SE, 0.2; P = .04). Performance rates increased significantly immediately after initiation for pain assessment (7.6% [SE, 2.0%], P = .002), sedation assessment (9.1% [SE, 3.7%], P = .02), and family engagement (7.8% [SE, 3%], P = .02) and then increased monthly at the same speed as the trend in the baseline period. Performance rates were lowest for spontaneous awakening/breathing trials and early mobility.

CONCLUSIONS

Quality improvement collaborative participation resulted in clinically meaningful, but small and variable, improvements in bundle performance. Opportunities remain to improve adoption of sedation, mechanical ventilation, and early mobility practices.

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

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.

Delirium in critical illness: clinical manifestations, outcomes, and management

Delirium is the most common manifestation of brain dysfunction in critically ill patients. In the intensive care unit (ICU), duration of delirium is independently predictive of excess death, length of stay, cost of care, and acquired dementia. There are numerous neurotransmitter/functional and/or injury-causing hypotheses rather than a unifying mechanism for delirium. Without using a validated delirium instrument, delirium can be misdiagnosed (under, but also overdiagnosed and trivialized), supporting the recommendation to use a monitoring instrument routinely. The best-validated ICU bedside instruments are CAM-ICU and ICDSC, both of which also detect subsyndromal delirium. Both tools have some inherent limitations in the neurologically injured patients, yet still provide valuable information about delirium once the sequelae of the primary injury settle into a new post-injury baseline. Now it is known that antipsychotics and other psychoactive medications do not reliably improve brain function in critically ill delirious patients. ICU teams should systematically screen for predisposing and precipitating factors. These include exacerbations of cardiac/respiratory failure or sepsis, metabolic disturbances (hypoglycemia, dysnatremia, uremia and ammonemia) receipt of psychoactive medications, and sensory deprivation through prolonged immobilization, uncorrected vision and hearing deficits, poor sleep hygiene, and isolation from loved ones so common during COVID-19 pandemic. The ABCDEF (A2F) bundle is a means to facilitate implementation of the 2018 Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU (PADIS) Guidelines. In over 25,000 patients across nearly 100 institutions, the A2F bundle has been shown in a dose-response fashion (i.e., greater bundle compliance) to yield improved survival, length of stay, coma and delirium duration, cost, and less ICU bounce-backs and discharge to nursing homes.

Pain assessment of the adult sedated and ventilated patients in the intensive care setting: A scoping review

BACKGROUND

Pain is frequently encountered in the intensive care setting. Given the impact of pain assessment on patient outcomes and length of hospital stay, studies have been conducted to validate tools, establish guidelines and cast light on practices relating to pain assessment.

OBJECTIVE

To examine the extent, range and nature of the evidence around pain assessment practices in adult patients who cannot self-report pain in the intensive care setting and summarise the findings from a heterogenous body of evidence to aid in the planning and the conduct of future research and management of patient care. The specific patient cohort studied was the sedated/ ventilated patient within the intensive care setting.

DESIGN

A scoping review protocol utilised the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping review checklist (PRISMA-ScR).

METHODS

The review comprised of five phases: identifying the research question, identifying relevant studies, study selection, charting the data and collating, summarizing, and reporting the results. Databases were systematically searched from January to April 2020. Databases included were Scopus, Web of Science, Medline via Ovid, CINAHL COMPLETE via EBSCO host, Health Source and PUBMED. Limits were applied on dates (2000 to current), language (English), subject (human) and age (adult). Key words used were "pain", "assessment", "measurement", "tools", "instruments", "practices", "sedated", "ventilated", "adult". A hand search technique was used to search citations within articles. Database alerts were set to apprise the availability of research articles pertaining to pain assessment practices in the intensive care setting.

RESULTS

The review uncovered literature categorised under five general themes: behaviour pain assessment tools, pain assessment guidelines, position statements and quality improvement projects, enablers and barriers to pain assessment, and evidence appertaining to actual practices. Behaviour pain assessment tools are the benchmark for pain assessment of sedated and ventilated patients. The reliability and validity of physiologic parameters to assess pain is yet to be determined. Issues of compliance with pain assessment guidelines and tools exist and impact on practices. In some countries like Australia, there is a dearth of information regarding the prevalence and characteristics of patients receiving analgesia, type of analgesia used, pain assessment practices and the process of recording pain management. In general, pain assessment varies across different intensive care settings and lacks consistency.

CONCLUSION

Research on pain assessment practices requires further investigation to explore the causative mechanisms that contribute to poor compliance with established pain management guidelines. The protocol of this review was registered with Open Science Framework (https://osf.io/25a6) Tweetable abstract: Pain assessment in intensive care settings lacks consistency. New information is needed to understand the causative mechanisms underpinning poor compliance with guidelines.

Delirium and long term cognition in critically ill patients

Delirium, a form of acute brain dysfunction, is very common in the critically ill adult patient population. Although its pathophysiology is poorly understood, multiple factors associated with delirium have been identified, many of which are coincident with critical illness. To date, no drug or non-drug treatments have been shown to improve outcomes in patients with delirium. Clinical trials have provided a limited understanding of the contributions of multiple triggers and processes of intensive care unit (ICU) acquired delirium, making identification of therapies difficult. Delirium is independently associated with poor long term outcomes, including persistent cognitive impairment. A longer duration of delirium is associated with worse long term cognition after adjustment for age, education, pre-existing cognitive function, severity of illness, and exposure to sedatives. Interestingly, differences in prevalence are seen between ICU survivor populations, with survivors of acute respiratory distress syndrome experiencing higher rates of cognitive impairment at early follow-up compared with mixed ICU survivor populations. Although cognitive performance improves over time for some ICU survivors, impairment is persistent in others. Studies have so far been unable to identify patients at higher risk of long term cognitive impairment; this is an active area of scientific investigation.

Health Promotion Among Long-Term ICU Patients and Their Families

Few patients are as helpless and totally dependent on nursing as long-term intensive care (ICU) patients. How the ICU nurse relates to the patient is crucial, both concerning the patients’ mental and physical health and well-being. Even if nurses provide evidence-based care in the form of minimum sedation, early mobilization, and attempts at spontaneous breathing during weaning, the patient may not have the strength, courage, and willpower to comply. Interestingly, several elements of human connectedness have shown a positive influence on patient outcomes. Thus, a shift from technical nursing toward an increased focus on patient understanding and greater patient and family involvement in ICU treatment and care is suggested. Accordingly, a holistic view including the lived experiences of ICU care from the perspectives of patients, family members, and ICU nurses is required in ICU care as well as research.

Considerable research has been devoted to long-term ICU patients’ experiences from their ICU stays. However, less attention has been paid to salutogenic resources which are essential in supporting long-term ICU patients’ inner strength and existential will to keep on living. A theory of salutogenic ICU nursing is highly welcome. Therefore, this chapter draws on empirical data from three large qualitative studies in the development of a tentative theory of salutogenic ICU nursing care. From the perspective of former long-term ICU patients, their family members, and ICU nurses, this chapter provides insights into how salutogenic ICU nursing care can support and facilitate ICU patients’ existential will to keep on living, and thus promoting their health, survival, and well-being. In a salutogenic perspective on health, the ICU patient pathway along the ease/dis-ease continuum reveals three stages; (1) The breaking point, (2) In between, and (3) Never in my mind to give up. The tentative theory of salutogenic long-term ICU nursing care includes five main concepts: (1) the long-term ICU patient pathway (along the salutogenic health continuum), (2) the patient’s inner strength and willpower, (3) salutogenic ICU nursing care (4), family care, and (5) pull and push. The salutogenic concepts of inner strength, meaning, connectedness, hope, willpower, and coping are of vital importance and form the essence of salutogenic long-term ICU nursing care.

Implementation of ABCDEF care bundle in intensive care units: A cross-sectional survey

BACKGROUND

Delirium affects up to 80% of patients in intensive care units (ICUs) and is associated with higher mortality, physical dependence, and health care costs. The 2018 pain, agitation, delirium, immobility, and sleep guideline recommended ABCDEF care bundle for delirium prevention and management. However, limited information is available regarding the adoption of the care bundle in ICUs in Mainland China.

AIMS AND OBJECTIVES

To assess the current implementation of the ABCDEF care bundle for delirium prevention as reported by ICU nurses in Mainland China.

DESIGN

A cross-sectional study was conducted.

METHODS

A cross-sectional online survey using a validated questionnaire about the practices of the ABCDEF care bundle was conducted among 334 registered nurses in 167 ICUs of 65 cities in Mainland China.

RESULTS

Almost 50% of the sampled ICU nurses were unaware of the ABCDEF care bundle, though 86.83% of the surveyed ICUs implemented pain assessments and 95.51% implemented sedation assessments. Nearly half (46.41%) of the surveyed ICUs performed routine spontaneous awaking trials, with 21.26% performing them daily. Spontaneous breathing trials were performed in 38.32% of the surveyed ICUs. Only 47% of the surveyed ICUs routinely monitored patients for delirium. About one-third (38.35%) of the surveyed ICUs were supported by specialist teams that implemented the mobilization programmes. Most ICUs restricted the duration of family visits per day (<0.5 hour: 61.67%; 0.5-2 hours: 23.65%; >2 hours: 3.29%) and only 28.14% of the surveyed ICUs employed dedicated staff to support the families.

CONCLUSIONS

Although most of the surveyed ICUs implemented pain and sedation assessments, many of them did not implement structured delirium assessments. Early mobilization programmes and family participation should be encouraged.

RELEVANCE TO CLINICAL PRACTICE

Promoting the uses of a reliable delirium assessment tool such as Confusion Assessment Method for Intensive Care Unit patients, building an early mobilization team, and engaging family caregivers in the care plan may contribute to improved patients' clinical outcomes.

A qualitative study of long-term ICU patients' inner strength and willpower: Family and health professionals as a health-promoting resource

AIMS AND OBJECTIVES

To explore how the presence of family and health professionals influences long-term critically ill patients' inner strength and willpower as an incitement to keep fighting for recovery.

BACKGROUND

This study reports long-term critically ill patients' experiences of family and health professionals as health-promoting resources in terms of significance for their inner strength and willpower. Earlier research on this topic is scarce.

DESIGN

A qualitative, hermeneutic-phenomenological approach, within the context of Antonovsky's salutogenic theory.

METHODS

Seventeen long-term critically ill patients were interviewed once, at 6-18 months after ICU discharge. The consolidated criteria for reporting qualitative research (COREQ) were used (Supplementary File 1).

RESULTS

Four main themes identified how family and staff promoted and challenged the patient's inner strength and willpower: (a) the importance of family and friends; my family was surrounding me, (b) staff contributions, (c) challenges to inner strength and willpower in relation to family and (d) loneliness and indifferent care.

CONCLUSION

This study brings new knowledge from the long-term critically ill patient's view about the impact of family, friends and nurses on the patient's inner strength and willpower. All impact is experienced positively and negatively.

RELEVANCE TO CLINICAL PRACTICE

Knowledge from the long-term critically ill patient's view is vital in nurse-patient interactions to facilitate liberation of inner strength and willpower.

Dialogue avec l’entourage des patients en réanimation

La place donnée à l’entourage de nos patients a accompli un changement profond dans les réanimations. Travailler à des discussions collégiales avec les soignants, reconnaître la parole des patients mais aussi de leurs proches dans les projets de soins est devenu une part obligatoire de notre travail quotidien. Ce changement de considération se perçoit aussi dans l’attention accordée aux partages des décisions éthiques. La confiance dans le système de soins comme auprès des intervenants médicaux est nécessaire pour que la relation thérapeutique puisse se faire sereinement. Il nous faut donc s’organiser pour perfectionner l’accueil des familles, la place de l’équipe, les réunions formelles régulières d’information auprès des proches ou du représentant de notre patient. Le stress post traumatique n’est pas seulement l’apanage des patients rescapés de réanimation, il est décrit aussi chez les accompagnants. Si la confiance est acquise, peu de conflits avec la famille sont insurmontables, seuls les conflits interfamiliaux obligent l’équipe médicale à défendre son opinion. La prise de conscience qu’un projet de soin à la sortie de réanimation réussira mieux quand il se fait avec l’appui de l’entourage, permet de comprendre l’importance à accorder aux proches et à leur stress.

Strategies to Optimize ICU Liberation (A to F) Bundle Performance in Critically Ill Adults With Coronavirus Disease 2019

Supplemental Digital Content is available in the text.

Objectives:

The severe acute respiratory syndrome coronavirus 2 pandemic has stretched ICU resources in an unprecedented fashion and outstripped personal protective equipment supplies. The combination of a novel disease, resource limitations, and risks to medical personnel health have created new barriers to implementing the ICU Liberation (“A” for Assessment, Prevention, and Manage pain; “B” for Both Spontaneous Awakening Trials and Spontaneous Breathing Trials; “C” for Choice of Analgesia and Sedation; “D” for Delirium Assess, Prevent, and Manage; “E” for Early Mobility and Exercise; and “F” for Family Engagement and Empowerment [ABCDEF]) Bundle, a proven ICU care approach that reduces delirium, shortens mechanical ventilation duration, prevents post-ICU syndrome, and reduces healthcare costs. This narrative review acknowledges barriers and offers strategies to optimize Bundle performance in coronavirus disease 2019 patients requiring mechanical ventilation.

Data Sources, Study Selection, and Data Extraction:

The most relevant literature, media reports, and author experiences were assessed for inclusion in this narrative review including PubMed, national newspapers, and critical care/pharmacology textbooks.

Data Synthesis:

Uncertainty regarding coronavirus disease 2019 clinical course, shifts in attitude, and changes in routine behavior have hindered Bundle use. A domino effect results from: 1) changes to critical care hierarchy, priorities, and ICU team composition; 2) significant personal protective equipment shortages cause; 3) reduced/restricted physical bedside presence favoring; 4) increased depth of sedation and use of neuromuscular blockade; 5) which exacerbate drug shortages; and 6) which require prolonged use of limited ventilator resources. Other identified barriers include manageable knowledge deficits among non-ICU clinicians unfamiliar with the Bundle or among PICU specialists deploying pediatric-based Bundle approaches who are unfamiliar with adult medicine. Both groups have been enlisted to augment the adult ICU work force to meet demand. Strategies were identified to facilitate Bundle performance to liberate patients from the ICU.

Conclusions:

We acknowledge current challenges that interfere with comprehensive management of critically ill patients during the coronavirus disease 2019 pandemic. Rapid response to new circumstances precisely requires established safety mechanisms and protocols like the ABCDEF Bundle to increase ICU and ventilator capacity and help survivors maximize recovery from coronavirus disease 2019 as early as possible.

COVID-19: What do we need to know about ICU delirium during the SARS-CoV-2 pandemic?

In March 2020, the World Health Organisation announced the COVID-19 pandemic caused by the SARS-CoV-2 virus. As well as respiratory failure, the SARS-CoV-2 may cause central nervous system (CNS) involvement, including delirium occurring in critically ill patients (ICU delirium). Due attention must be paid to this subject in the face of the COVID-19 pandemic. Delirium, the detection of which takes less than two minutes, is frequently underestimated during daily routine ICU care, but it may be a prodromal symptom of infection or hypoxia associated with severe respiratory failure. During the COVID-19 pandemic, systematic delirium monitoring using validated tests (CAM-ICU or ICDSC) may be sacrificed. This is likely to be due to the fact that the main emphasis is placed on organisational issues, i.e. the lack of ventilators, setting priorities for limited mechanical ventilation options, and a shortage of personal protective equipment. Early identification of patients with delirium is critical in patients with COVID-19 because the occurrence of delirium may be an early symptom of worsening respiratory failure or of infectious spread to the CNS mediated by potential neuroinvasive mechanisms of the coronavirus. The purpose of this review is to identify problems related to the development of delirium during the COVID-19 epidemic, which are presented in three areas: i) factors contributing to delirium in COVID-19, ii) potential pathophysiological factors of delirium in COVID-19, and iii) long-term consequences of delirium in COVID-19. This article discusses how healthcare workers can reduce the burden of delirium by identifying potential risk factors and difficulties during challenges associated with SARS-CoV-2 infection.