Implementation Strategies Used to Facilitate ABCDEF Bundle Adoption: Scoping Review
Problem: Administration of the ABCDEF bundle (A – Assess, prevent, and manage pain; B – Both spontaneous awakening trials and spontaneous breathing trials; C – Choice of analgesia and sedation; D – Delirium: assess, prevent, and manage; E – Early mobility/exercise; F – Family engagement/empowerment) is associated with improvements in a number of important patient-centered outcomes. Despite its demonstrated safety and effectiveness, overall adoption of the ABCDEF bundle and its individual components into everyday clinical practice remains low.
Purpose: The purpose of the scoping review is to identify strategies used by prior studies and quality improvement (QI) efforts to facilitate ABCDEF bundle implementation and critically evaluate the implementation strategies to facilitate adoption of this evidence-based, interprofessional intervention.
Methods: A scoping review of electronic databases (CINAHL, PubMed, Web of Science, Scopus, PsychInfo, Medline) was completed. Research studies, QI projects, systematic reviews, or metanalyses published from 2009-2020, in English and available as full-text articles which described implementation of either the ABCDE bundle or ABCDEF bundle in the intensive care unit were eligible for inclusion. Studies that did not explicitly mention the ABCDE or ABCDEF bundle, were conducted with the pediatric population, or focused only on one element of the bundle (e.g., early mobility) were excluded. The Expert Recommendations for Implementing Change (ERIC) compilation provided 73 implementation strategies used to guide data extraction. Content analysis was performed, and summary statistics were reported.
Results: Ten studies were eligible after screening 368 titles and abstracts and reviewing 23 full-text studies. Implementation efforts used an average of 35.6 strategies (SD=12.9), ranging from eight to 54. The most utilized implementation strategies were: “Develop an implementation glossary,” “Develop educational materials,” “Facilitation,” “Provide clinical supervision,” and “Recruit, designate, and train for leadership”. 17 ERIC strategies were not used and, importantly, no studies reported testing the effectiveness of the strategies used.
Implications for practice: Future evaluation of implementation strategies used in ABCDEF bundle implementation is essential to effectively allocate efforts and resources. Research trials must identify, test, and report the specific methods and resources needed for effective and sustained ABCDEF bundle implementation. Until effective implementation is understood, the excessively high morbidity, mortality, and cost associated with standard critical care delivery will continue and the public health benefit of the ABCDEF bundle will not be fully realized.
Keywords: ABCDEF bundle, implementation, barriers, facilitators, intensive care unit, ICU