Nurses' Role in Implementing the ABCDEF Bundle.

Abstract

I read the articles regarding implementing the ABCDEF bundles in the intensive care unit (ICU) and the positive impact the bundle has on patients’ length of stay, complications, and family involvement (“Implementing the ABCDEF Bundle: Top 8 Questions Asked During the ICU Liberation ABCDEF Bundle Improvement Collaborative” [2019;39(1):36-45] and “Common Challenges to Effective ABCDEF Bundle Implementation: The ICU Liberation Campaign Experience” [2019;39(1):46-60]). I read these articles with interest, but 1 thing that stood out to me was the qualifications of the Collaborative: there was not 1 bedside registered nurse (RN) on the team. Can we acknowledge that the main implementer of this bundle is the RN who is at the bedside for 12 hours? I am not downplaying the importance of physicians, respiratory therapists, physical therapists (PTs), occupational therapists (OTs), pharmacists, spiritual counselors, social workers, etc, in the patient’s journey in the ICU, but, in the case of PTs, OTs, and spiritual counselors, they are in physical contact with the patient and family for, at most, 60 minutes. The RN is the one who sits by the delirious patient’s bedside at 4 am when the daily spontaneous awakening and spontaneous breathing trials are done, making sure the patient does not pull out the endotracheal tube or climb out of bed. Physical therapists and OTs are instrumental in implementing early mobility, but a critically ill patient who has many tubes and lines requires, at minimum, the therapist and the RN for early mobility. A less critically ill patient at minimum needs a gait belt, walker, and careful lifting, and the PT or OT is apt to say, “he/she should get up a few more times today,” which becomes the RN’s responsibility. The family of a critically ill patient is offered support from the spiritual counselor, but who does the family talk with after that counselor is gone—the RN.I have been a critical care RN for many years. I love my job and I know it includes everything from trying to get patients off the ventilator, supporting a grieving family, to slinging a 400-pound patient to the chair. I work in a dynamic ICU that tries its best at implementing the ABCDEF bundle; we have designated, hard-working PTs and OTs; we have twice-daily team rounding with the intensivist and everyone else involved in the patient’s care—including the family; and we are always actively trying to avoid delirium with careful drug choices, early mobility, and family involvement. However, our well-compensated top management has cut our staffing, getting rid of several key supportive bedside positions. The safety of our patients is at stake: I am not about to get a precarious patient out of bed if I do not have the physical support. We can help each other, but with unstable and/or delirious patients, demanding families, and the massive documentation we are required to do there is not enough time, energy, or mental fortitude to always practice nursing in the most effective way and consistently implement the ABCDEF bundle. That should have been one of the common challenges and questions discussed in these articles: “How does the cutting of bedside staff and the recent large increase in CEO pay affect your ability and aspiration to effectively implement the ABCDEF bundle?”I am at the end of my RN journey, but I worry about the young RNs and the future of bedside nursing. Nearly every month another staff nurse leaves to pursue a career away from the bedside. If this continues, with increased expectations, workloads, and compliance requirements, while cutting costs by cutting staff, I fear there are going to be few experienced bedside nurses left, and those who stay are going to be exhausted and burned out, to the detriment of themselves, patients, and families.