Disclosure(s): Baxter Healthcare: Advisory Board (Terminated, February 1, 2025), Speaker/Honoraria (includes speakers bureau, symposia, and expert witness) (Terminated, February 1, 2025)
First Author: Elizabeth Munroe, MD, MSc – Intermountain Health Care Co-Author: Harsh Bhanderi, MS – Database Analyst/Programmer, Michigan Hospital Medicine Safety Consortium Co-Author: Tawny Czilok, MHI, BSN, RN – Assistant Program Manager, Michigan Hospital Medicine Safety Consortium Co-Author: Lokesh Dayal, MD – Central Michigan University School of Medicine Co-Author: Rania Esteitie, MD – Assistant Professor, Covenant Healthcare Co-Author: Rachel K. Hechtman, MD – University of Michigan Co-Author: Jennifer Horowitz, MA – Research Area Specialist, Michigan Hospital Medicine Safety Consortium Co-Author: Elizabeth McLaughlin, MS, RN – Clinical Information Analyst, Michigan Hospital Medicine Safety Consortium Co-Author: Maximiliano Kakazu, MD – Corewell Health - Michigan State University Co-Author: Caitlin Tatarcuk, BSN, RN – Quality Assurance Coordinator, Michigan Hospital Medicine Safety Consortium Co-Author: Emily Walzl, MS – Statistician, Michigan Hospital Medicine Safety Consortium Co-Author: Elizabeth M. Viglianti, MD MPH MSc – Assistant Professor, Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Michigan Co-Author: Hallie Prescott, MD, MSc, FACP – University of Michigan Co-Author: Scott A. Flanders, MD – Professor, University of Michigan Co-Author: Paul Bozyk, MD – Associate Professor, Corewell Health
Introduction: Compliance with the ABCDEF bundle has been associated with improved mortality and shorter ICU stays in critically ill patients. However, implementation of bundle elements varies in practice. We aimed to assess implementation and monitoring of the ABCDEF bundle across Michigan hospitals.
Methods: We surveyed hospitals in the Michigan Hospital Medicine Safety Consortium (HMS), a quality initiative sponsored by Blue Cross Blue Shield of Michigan. HMS includes diverse hospitals, ranging from small community to large academic sites. Surveys were completed in spring 2025 by each hospital’s HMS representative. The survey included questions about implementation of ABCDEF bundle elements and bundle-related safety screens and approaches to monitoring bundle compliance.
Results: 67/68 (98.5%) hospitals completed this survey. 62 (92.5%) reported implementing at least one ABCDEF bundle element: Assessment, prevention, and management of pain (N=62), both spontaneous awakening and breathing trials [SAT/SBT] (N=62), choice of sedation (N=59), delirium assessment, prevention, and management (N=61), early mobility (N=60), and family engagement (N=59). Of the 62 hospitals who have implemented bundle elements, 14 (22.6%) do not routinely monitor compliance, 22 (35.5%) use one method to monitor compliance, and 26 (41.9%) use multiple methods to monitor compliance. Most common methods for monitoring compliance were built-in electronic health record tools (N=34), documentation in the health record (e.g., structured notes, N=19), and non-electronic checklists (N=15). Only 32 (51.6%) hospitals use the SCCM ICU Liberation definitions to determine bundle compliance. Most hospitals reported using standard nursing or respiratory therapist-led SAT/SBT protocols (N=37; 59.7%) and early mobility safety screening (N=53; 85.5%). However, 22 (35.5%) required a physician order to proceed with SAT/SBT and 9 (14.5%) reported having limited resources to support early mobility.
Conclusions: In this statewide hospital survey, most hospitals report implementation of the ABCDEF bundle but approaches to monitoring compliance vary and there is differential use of standard definitions and protocols. This suggests an opportunity to standardize ABCDEF bundle implementation and monitoring to improve outcomes for critically ill patients.
