The ABCDEF (ICU liberation) bundle and early mobility

What it is

The ABCDEF bundle, also called the ICU liberation bundle, puts six evidence-based practices together so that they are done every day for every eligible patient. Each element supports the others: controlled pain allows lighter sedation, lighter sedation allows awakening and breathing trials and mobility, and fewer sedatives mean less delirium. In a collaborative of more than 15,000 adults, doing all eligible elements on a day was associated with lower mortality and less next-day ventilation, coma, delirium and physical restraint. The nurse is central to almost every element, from pain and sedation scores to mobility and inviting the family.

What it requires

• The bundle is a daily checklist, not a sequence: every eligible element is done each day.
• Weakness acquired in the ICU is common; muscle strength falls within days of ventilation and loss can last for years.
• Physical therapy has been done safely even in patients on continuous renal replacement or extracorporeal support.
• Families on rounds feel more included, and their presence does not disturb teaching or communication.

Components

• A: pain scale and analgesia plan (see the analgesia and pain scale pages).
• B: the safety screens and the protocol for the awakening and breathing trials.
• C: the sedation target and the choice of drugs (lighter, non-benzodiazepine options often preferred).
• D: the delirium tool each shift and the non-drug prevention measures.
• E: a mobility plan built with physiotherapy (from sitting in bed to walking).
• F: flexible family presence, information and participation in care and decisions.

How it is applied (and why)

1. Go through the six elements each shift and mark which apply today: an element that is not checked is easily skipped.
2. Score pain and treat it per order before procedures and mobility: pain stops patients from moving.
3. Run the awakening trial with the team and then the breathing trial: done together they lower sedative use and shorten ventilation.
4. Keep sedation at the ordered target, lightest possible: a patient who is awake can take part in mobility.
5. Screen for delirium each shift and report a positive result: it changes the plan of the day.
6. Mobilise with physiotherapy at the level the patient tolerates, with lines and tube secured: movement is the measure most linked to fewer delirium days.
7. Invite the family to rounds and to simple care, and give them information: family participation is linked to less delirium, and families feel more included.
8. Avoid restraints when possible and reassess them each shift: full bundle performance was associated with less restraint use.

In nursing practice

• If an element is not done, record why (for example a failed safety screen): it is part of the bundle's audit.
• Mobility is stopped if the patient becomes unstable, following the unit's criteria; it is tried again later.
• More pain is often found as the bundle improves: that reflects better detection, not worse care.
• Rehabilitation continues after the ICU; tell the next team what level of mobility the patient reached.

Common mistakes

• Treating the bundle as a paper exercise: the elements only help if they are actually done at the bedside.
• Raising sedation for agitation without first checking pain and delirium.
• Waiting for the patient to be «stable enough» for days before any mobility, without asking the team.
• Keeping the family away from care and information when they could take part.

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Connections

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Educational content for students; it does not replace your institution's protocols, supervised clinical training or a prescriber's order. Dose-calculation examples use made-up numbers: they are educational, not a clinical order.

Sources: Caring for Critically Ill Patients with the ABCDEF Bundle: Results of the ICU Liberation Collaborative in Over 15,000 Adults (Pun BT et al.) (Critical Care Medicine, author manuscript in PubMed Central, 2019); The ABCDEF Bundle in Critical Care (Marra A, Ely EW, Pandharipande PP, Patel MB) (Critical Care Clinics, author manuscript in PubMed Central, 2017); A systematic meta-review of interventions to prevent and manage delirium in the Intensive Care Unit: Part 2, non-pharmacological and multicomponent interventions (Kundakci B et al.) (Critical Care, PubMed Central, 2025).

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Representative model, for educational purposes only.