Worldwide Survey of the "Assessing Pain, Both Spontaneous Awakening and Breathing Trials, Choice of Drugs, Delirium Monitoring/Management, Early Exercise/Mobility, and Family Empowerment" (ABCDEF) Bundle

Alessandro Morandi, Ancelle Hospital
Simone Piva, SpedaliCivili University Hospital
Wesley Ely, Vanderbilt University
Sheila Nainan Myatra, Tata Memorial Hospital
Jorge I.F. Salluh, Federal University of Rio de Janeiro
Dawit Amare, Addis Hiwot General Hospital
Elie Azoulay, Paris Diderot Sorbonne University
Giuseppe Bellelli, San Gerardo University Hospital
Akos Csomos, Hungarian Defence Force
Eddy Fan, University of Toronto
Nazzareno Fagoni, SpedaliCivili University Hospital
Timothy D. Girard, University of Pittsburgh and UPMC Health System
Gabriel Heras La Calle, Hospital Universitario de Torrejón
Shigeaki Inoue, Tokai University
Chae-Man Lim, University of Ulsan College of Medicine
Rafael Kaps, General Hospital Novo mesto
Katarzyna Kotfis, Pomeranian Medical University
Younsuck Koh, University of Ulsan College of Medicine
David Misango, Aga Khan University
Pratik P. Pandharipande, Vanderbilt University Medical Center
Chairat Permpikul, Siriraj Hospital
Cheng Cheng Tan, Peking University First Hospital
Dong-Xin Wang, Peking University First Hospital
Tarek Sharshar, Raymond Poincaré Hospital
Yahya Shehabi, Monash University


Objectives: To assess the knowledge and use of the Assessment, prevention, and management of pain; spontaneous awakening and breathing trials; Choice of analgesia and sedation; Delirium assessment; Early mobility and exercise; and Family engagement and empowerment (ABCDEF) bundle to implement the Pain, Agitation, Delirium guidelines.

Design: Worldwide online survey. Setting: Intensive care. Intervention: A cross-sectional online survey using the Delphi method was administered to intensivists worldwide, to assess the knowledge and use of all aspects of the ABCDEF bundle. Measurement and Main Results: There were 1,521 respondents from 47 countries, 57% had implemented the ABCDEF bundle, with varying degrees of compliance across continents. Most of the respondents (83%) used a scale to evaluate pain. Spontaneous awakening trials and spontaneous breathing trials are performed in 66% and 67% of the responder ICUs, respectively. Sedation scale was used in 89% of ICUs. Delirium monitoring was implemented in 70% of ICUs, but only 42% used a validated delirium tool. Likewise, early mobilization was "prescribed" by most, but 69% had no mobility team and 79% used no formal mobility scale. Only 36% of the respondents assessed ICU-acquired weakness. Family members were actively involved in 67% of ICUs; however, only 33% used dedicated staff to support families and only 35% reported that their unit was open 24 hr/d for family visits.

Conclusions: The current implementation of the ABCDEF bundle varies across individual components and regions. We identified specific targets for quality improvement and adoption of the ABCDEF bundle. Our data reflect a significant but incomplete shift toward patient- and family-centered ICU care in accordance with the Pain, Agitation, Delirium guidelines.