The A2F Bundle: Quantity and Quality Matter.

Abstract

The ICU Liberation Campaign was launched in 2014 by the Society of Critical Care Medicine (SCCM) to improve patientand family-centered care by promoting the widespread adoption of SCCM’s 2013 clinical practice guidelines for the management of pain, agitation, and delirium and the subsequent 2018 guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU (1–3). At the bedside, the ICU Liberation Campaign, a quality-improvement collaborative, empowers the interprofessional team to implement effectively the ABCDEF, or A2F, bundle. The ABCDEF bundle strives to optimize pain management through assessment and prevention, avoid deep sedation, reduce delirium, and shorten the duration of mechanical ventilation through both spontaneous awakening and breathing trials and through choice of analgesia and sedation, minimize ICUacquired weakness through early mobility, and foster ICU patient and family engagement in care processes. Beyond these short-term benefits, the A2F bundle holds promise as a strategy to improve long-term outcomes after critical illness as well, in part due to the known association between duration of delirium and long-term cognitive and physical impairments (4–6). The evidence supporting A2F bundle adoption is robust (7–11) and continues to build. Yet, important questions exist about how individual bundle components interact and the degree to which increased pain, sedation, and delirium screening influence the delivery of key interventions like early mobility and, ultimately, patient-centered outcomes. Two such questions relate to delirium. First, does the bundle reduce the frequency with which ICU patients experience delirium? Second, and related, does the bundle reduce the duration of delirium? In this issue of Critical Care Medicine, Zhang et al (12) conducted a systematic review and meta-analyses to evaluate the effectiveness of bundle interventions on patient outcomes, with a focus on the development and duration of delirium. By focusing on studies that examined A2F interventions, and not just delirium screening improvements, the authors were positioned to examine these important questions. By design, the primary outcomes of the study were delirium prevalence and duration. Secondary outcomes included the following: duration of mechanical ventilation, ventilator-free days, ICU and hospital length of stay, and mortality, measured as ICU, inhospital, and 28-day mortalities. The authors rigorously adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, graded study quality prior to inclusion, assessed for heterogeneity and publication bias, and conducted multiple secondary analysis to substantiate their results and conclusions. The systematic review included 11 studies, enrolling 26,384 adult patients, which implemented at least three of the six A2F bundle components. Among Mark E. Mikkelsen, MD, MSCE, FCCM1,2