ABCDEF Bundle and Supportive ICU Practices for Patients With Coronavirus Disease 2019 Infection: An International Point Prevalence Study

Abstract

Objectives: To investigate implementation of evidence-based and supportive cares in ICUs, such as the ABCDEF, nutrition therapy, and ICU diary, for patients with coronavirus disease 2019 infection in ICUs and their association with ICU clinical practice and setting.

Design: A worldwide, 2-day point prevalence study.

Setting: The study was carried out on June 3, 2020, and July 1, 2020. A total of 212 ICUs in 38 countries participated. Clinicians in each participating ICU completed web-based online surveys.

Patients: The ICU patients with coronavirus disease 2019.

Interventions: None.

Measurements and main results: The implementation rate for the elements of the ABCDEF bundle, other supportive ICU care measures, and implementation-associated structures were investigated. Data were collected for 262 patients, of whom 47.3% underwent mechanical ventilation and 4.6% were treated with extracorporeal membrane oxygenation. Each element was implemented for the following percentages of patients: elements A (regular pain assessment), 45%; B (both spontaneous awakening and breathing trials), 28%; C (regular sedation assessment), 52%; D (regular delirium assessment), 35%; E (early mobility and exercise), 47%; and F (family engagement and empowerment), 16%. The implementation of element E was 4% for patients on mechanical ventilation and 8% for patients on extracorporeal membrane oxygenation. Supportive care, such as protein provision throughout the ICU stay (under 1.2 g/kg for more than 50% of the patients) and introduction of ICU diary (25%), was infrequent. Implementation rates of elements A and D were higher in ICUs with specific protocols and fewer ICU beds exclusively for patients with coronavirus disease 2019 infection. Element E was implemented at a higher rate in ICUs that had more ICU beds assigned for them.

Conclusions: This point prevalence study showed low implementation of the ABCDEF bundle. Specific protocols and the number of ICU beds reserved for patients with coronavirus disease 2019 infection might be key factors for delivering appropriate supportive care.

Keywords: intensive care unit liberation bundle; novel coronavirus; pandemic; postintensive care syndrome; quality improvement; supportive care.

Conflict of interest statement

Some authors report potential conflicts of interest outside of this submitted study. Dr. Nakamura reports personal fees from Abbott Laboratory, Nestle, Terumo, Getinge, Asahi Kasei Pharma, Ono Pharmaceutical, Japan Blood Products Organization, Nihon Pharmaceutical, Otsuka Pharmaceutical, Pfizer, Toray, and Baxter, and grants from Asahi Kasei Pharma outside the submitted work. Dr. Katsukawa receives a salary from the Japanese Society for Early Mobilization (nonprofit society) as a chair (full time) outside the submitted work. Dr. Ely reports grants from the Department of Veterans Affairs and the National Institutes of Health; personal fees from Pfizer, Orion, and Lilly; personal fees from Masimo; and grants from Kohler outside the submitted work. Dr. Inoue reports personal fees from Abbott Laboratory, Teijin Pharma, Nestle, and Nihon Pharmaceutical. Dr. Nishida reports grants from Asahi Kasei Pharma, Ono Pharmaceutical, Baxter, Maruishi Pharmaceutical, Torii Pharmaceutical, Teijin Pharma, Shionogi Pharmaceutical, and Fuso Pharmaceutical outside the submitted work. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.

Figures

Figure 1.

Study flowchart. aOf 212 ICUs, 166 ICUs had completed the basic information for the hospital on the first survey date and did not need to complete the basic information on the second survey. These 166 hospitals were requested to complete the survey of daily ICU care on the second survey date by using the facility registration number issued during the first survey. bThe median number of patients (interquartile range, 1–3) was registered from each participating hospital on the first and second dates. COVID-19 = coronavirus disease 2019.

Figure 2.

Implementation of each element of the ABCDEF bundle. Statistical comparisons were made between two groups in elements A, B, and C, and between three groups in elements D, E, and F. aOf 12 patients supported with extracorporeal membrane oxygenation (ECMO), 11 received mechanical ventilation at the same time and one did not. bThe group for element B (spontaneous breathing trial) was excluded from this figure, because spontaneous breathing trials were conducted only for patients undergoing mechanical ventilation. SAT = spontaneous awakening trials.

Figure 3.

Highest mobility level and nutrition therapy provided according to the phase of critical illness. A, The highest mobility level of all patients. B, The highest mobility level of patients undergoing mechanical ventilation. C, The proportion of patients receiving the indicated total energy (kcal/d). D, The proportion of patients receiving the indicated protein (g/kg).