The ICU daily bundle (FAST HUGS and similar checklists)

What it is

Critically ill patients are at risk of many complications that do not come from their main illness: clots, pressure injuries, pneumonia, line infections, stomach bleeding, high or low glucose, delirium and weakness from immobility. Daily checklists turn the simple measures that prevent them into a routine that the whole team checks on the ward round. FAST HUGS (Feeding, Analgesia, Sedation, Thromboprophylaxis, Head-of-bed elevation, Ulcer prophylaxis, Glucose control) was later extended to FAST HUGS BID (Spontaneous breathing trial, Bowel care, Indwelling catheter removal, De-escalation of antibiotics). The ABCDEF bundle focuses on the liberation from ventilation and sedation: assess and manage pain, both spontaneous awakening and breathing trials, choice of analgesia and sedation, delirium assessment and prevention, early mobility, and family engagement. Paired daily sedation interruption and spontaneous breathing trials shorten ventilation and ICU stay. A checklist does not replace thought, but it catches omissions, gives nurses and junior doctors a structured voice, and links each item to a clear daily goal.

Key points

• Feeding: start enteral nutrition early when the gut works, rather than leaving the patient unfed.
• Analgesia and sedation: treat pain first and aim for light sedation unless there is a specific reason for deep sedation.
• Thromboprophylaxis: pharmacological unless bleeding risk forbids it, in which case mechanical compression devices are used.
• Head of the bed raised about thirty to forty-five degrees in ventilated patients to reduce aspiration and ventilator-associated pneumonia.
• Ulcer prophylaxis only for patients with risk factors, and glucose control that avoids both hyperglycaemia and hypoglycaemia.
• Bowel care to avoid constipation and diarrhoea, removal of unnecessary catheters, and narrowing antibiotics once cultures return.

Components

• A short written or electronic checklist read aloud on the round, with a named person responsible for each item.
• A daily goals sheet: what must happen today, what could go wrong, and when to call the senior.
• Linked prompts for safety checks: lines and their days in place, drug reconciliation, pressure areas, mobility and family updates.
• Goals of care and limits of treatment recorded and reviewed, especially when the illness is not improving.

How it works

• Busy teams forget routine prevention when attention is on the acute problem; a checklist makes the routine explicit.
• Each item targets a common ICU complication: venous thromboembolism, pressure injury, pneumonia, CLABSI, catheter-associated urinary infection, delirium and weakness.
• Reading the list aloud flattens hierarchy, so a nurse can raise a missed item without confrontation.

Step by step

1. Read the checklist aloud on every ward round — routine items are skipped when no one asks.
2. Agree the feeding plan and start early enteral nutrition when possible — undernutrition worsens recovery.
3. Assess pain, sedation and delirium with validated scales — targets only work when measured.
4. Pair a spontaneous awakening trial with a spontaneous breathing trial when safe — this shortens ventilation.
5. Confirm thromboprophylaxis, head-of-bed elevation and ulcer prophylaxis — each prevents a common complication.
6. Review glucose, bowels and every line and catheter, removing what is not needed — this reduces infection.
7. Narrow or stop antibiotics by culture results and planned duration — this limits resistance and C. difficile.
8. Write today's goals and update the family — a shared plan prevents errors and distress.

FAST HUGS BID

In practice

• A checklist used as a box-ticking exercise adds little; each item should lead to a decision recorded for that day.
• Daily sedation interruption is not done in active seizures, alcohol withdrawal, on neuromuscular blockers, with raised intracranial pressure or myocardial ischaemia.
• Thromboprophylaxis is withheld or switched to mechanical methods in active bleeding, very low platelets or before some procedures, and restarted when safe.
• Family engagement and clear communication reduce distress and help decisions about goals of care.

Next step

• Record the result of each checklist item and the day's goals in the notes or the electronic chart.
• Escalate to a senior any item that cannot be met, such as thromboprophylaxis held for bleeding or a failed breathing trial.
• Remove lines and catheters the same day they are judged unnecessary, and document it.
• Hold a family meeting when the plan changes or goals of care are discussed, and record what was agreed.
• Audit checklist compliance and complication rates regularly and feed the results back to the team.

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Elsewhere in DurgiPedia

• Mechanical prevention of venous thromboembolism: stockings and intermittent compression
• Preventing pressure injuries: risk scales, repositioning and skin care
• Indwelling catheter care and removal
• Complications of immobility and how to prevent them
• Limiting life-sustaining treatment: withholding and withdrawing

Connections

← All of anaesthesia

Educational content; it does not replace supervised training, your institution's protocols or the anaesthetist's or intensivist's decision. It contains no doses and no ventilator or infusion settings.

Sources: Sedation Vacation in the ICU (StatPearls (NCBI Bookshelf), 2025); Central Line–Associated Blood Stream Infections (StatPearls (NCBI Bookshelf), 2022).

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Representative model, for educational purposes only.