ICU Liberation Research Articles

Effect of Implementation ICU liberation bundle on Critically Ill patients Outcomes

Effect of Implementation ICU liberation bundle on Critically Ill patients Outcomes

Improving Outcomes in Mechanically Ventilated Adult ICU Patients Following Implementation of the ICU Liberation (ABCDEF) Bundle Across a Large Healthcare System.

To measure how the ICU Liberation Bundle (aka ABCDEF Bundle or the Bundle) affected clinical outcomes in mechanically ventilated (MV) adult ICU patients, as well as bundle sustainability and spread across a healthcare system. We conducted a multicenter, prospective, cohort observational study to measure bundle performance versus patient outcomes and sustainability in 11 adult ICUs at six community hospitals. We then prospectively measured bundle spread and performance across the other 28 hospitals of the healthcare system. A large community-based healthcare system. In 11 study ICUs, we enrolled 1,914 MV patients (baseline n = 925, bundle performance/outcomes n = 989), 3,019 non-MV patients (baseline n = 1,323, bundle performance/outcomes n = 1,696), and 2,332 MV patients (bundle sustainability). We enrolled 9,717 MV ICU patients in the other 28 hospitals to assess bundle spread. We used evidence-based strategies to implement the bundle in all 34 hospitals. We compared outcomes for the 12-month baseline and bundle performance periods. Bundle implementation reduced ICU length of stay (LOS) by 0.5 days (p = 0.02), MV duration by 0.6 days (p = 0.01), and ICU LOS greater than or equal to 7 days by 18.1% (p < 0.01). Performance period bundle compliance was compared with the preceding 3-month baseline compliance period. Compliance with pain management and spontaneous awakening trial (SAT) and spontaneous breathing trial (SBT) remained high, and reintubation rates remained low. Sedation assessments increased (p < 0.01) and benzodiazepine sedation use decreased (p < 0.01). Delirium assessments increased (p = 0.02) and delirium prevalence decreased (p = 0.02). Patient mobilization and ICU family engagement did not significantly improve. Bundle element sustainability varied. SAT/SBT compliance dropped by nearly half, benzodiazepine use remained low, sedation and delirium monitoring and management remained high, and patient mobility and family engagement remained low. Bundle compliance in ICUs across the healthcare system exceeded that of study ICUs. The ICU Liberation Bundle improves outcomes in MV adult ICU patients. Evidence-based implementation strategies improve bundle performance, spread, and sustainability across large healthcare systems.

The A2F ICU Liberation Bundle in Neurocritical Care

The A2F ICU Liberation Bundle in Neurocritical Care

Clinicians’ perceptions on implementation strategies used to facilitate ABCDEF bundle adoption: A multicenter survey

BackgroundIntensive care unit (ICU) clinicians struggle to routinely implement the ICU Liberation bundle (ABCDEF bundle). As a result, critically ill patients experience increased risk of morbidity and mortality. Despite extensive research related to the barriers and facilitators of bundle use, little is known regarding which implementation strategies are used to facilitate its adoption and sustainability. ObjectivesTo identify implementation strategies used to increase adoption of the ABCDEF bundle and how those strategies are perceived by end-users (i.e., ICU clinicians) related to their helpfulness, acceptability, feasibility, and cost. MethodsWe conducted a national, cross-sectional survey of ICU clinicians from the 68 ICU sites that previously participated in the Society of Critical Care Medicine's ICU Liberation Collaborative. The survey was structured using the 73 Expert Recommendations for Implementing Change (ERIC) implementation strategies. Surveys were delivered electronically to site contacts. ResultsNineteen ICUs (28%) returned completed surveys. Sites used 63 of the 73 ERIC implementation strategies, with frequent use of strategies that may be readily available to clinicians (e.g., providing educational meetings or ongoing training), but less use of strategies that require changes to well-established organizational systems (e.g., alter incentive allowance structure). Overall, sites described the ERIC strategies used in their implementation process to be moderately helpful (mean score >3<4 on a 5-point Likert scale), somewhat acceptable and feasible (mean score >2<3), and either not-at-all or somewhat costly (mean scores >1<3). ConclusionsOur results show a potential over-reliance on accessible strategies and the possible benefit of unused ERIC strategies related to changing infrastructure and utilizing financial strategies.

Caring for Critically Ill Children With the ICU Liberation Bundle (ABCDEF): Results of the Pediatric Collaborative.

Assess clinical outcomes following PICU Liberation ABCDEF Bundle utilization. Prospective, multicenter, cohort study. Eight academic PICUs. Children greater than 2 months with expected PICU stay greater than 2 days and need for mechanical ventilation (MV). ABCDEF Bundle implementation. Over an 11-month period (3-mo baseline, 8-mo implementation), Bundle utilization was measured for 622 patients totaling 5,017 PICU days. Risk of mortality was quantified for 532 patients (4,275 PICU days) for correlation between Bundle utilization and MV duration, PICU length of stay (LOS), delirium incidence, and mortality. Utilization was analyzed as subject-specific (entire PICU stay) and day-specific (single PICU day). Median overall subject-specific utilization increased from 50% during the 3-month baseline to 63.9% during the last four implementation months (p < 0.001). Subject-specific utilization for elements A and C did not change; utilization improved for B (0-12.5%; p = 0.007), D (22.2-61.1%; p < 0.001), E (17.7-50%; p = 0.003), and F (50-79.2%; p = 0.001). We observed no association between Bundle utilization and MV duration, PICU LOS, or delirium incidence. In contrast, on adjusted analysis, every 10% increase in subject-specific utilization correlated with mortality odds ratio (OR) reduction of 34%, p < 0.001; every 10% increase in day-specific utilization correlated with a mortality OR reduction of 1.4% (p = 0.006). ABCDEF Bundle is applicable to children. Although enhanced Bundle utilization correlated with decreased mortality, increased utilization did not correlate with duration of MV, PICU LOS, or delirium incidence. Additional research in the domains of comparative effectiveness, implementation science, and human factors engineering is required to understand this clinical inconsistency and optimize PICU Liberation concept integration into clinical practice.

Back to the Future: Evidence-Based Sedation Practices in the ICU?

Your Patient's Brain| July 2022 Back to the Future: Evidence-Based Sedation Practices in the ICU? Dusan Hanidziar, MD, PhD; Dusan Hanidziar, MD, PhD Search for other works by this author on: This Site PubMed Google Scholar Daniel J. Cole, MD, FASA; Daniel J. Cole, MD, FASA Search for other works by this author on: This Site PubMed Google Scholar Elizabeth Mahanna Gabrielli, MD Elizabeth Mahanna Gabrielli, MD Search for other works by this author on: This Site PubMed Google Scholar ASA Monitor July 2022, Vol. 86, 11–12. https://doi.org/10.1097/01.ASM.0000842024.01503.bb Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Cite Icon Cite Get Permissions Search Site Citation Dusan Hanidziar, Daniel J. Cole, Elizabeth Mahanna Gabrielli; Back to the Future: Evidence-Based Sedation Practices in the ICU?. ASA Monitor 2022; 86:11–12 doi: https://doi.org/10.1097/01.ASM.0000842024.01503.bb Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu toolbar search search input Search input auto suggest filter your search All ContentAll PublicationsASA Monitor Search Advanced Search Topics: evidence-based practice, intensive care unit, sedation procedure With the beginning of the COVID-19 pandemic, ICUs in the United States and around the world quickly reverted to practices that were common over two decades ago – the administration of deep sedation in mechanically ventilated patients, lack of daily spontaneous awakening and breathing trials, insufficient patient mobilization, and delayed tracheostomies, as well as less communication and restricted access for families. Although understandable in the midst of a national health care crisis, these practices likely contributed to prolonged mechanical ventilation, opioid and benzodiazepine dependance, increased prevalence of coma and delirium, and lingering physical and cognitive disability that continue to be reported in many COVID-19 ICU cohorts (Anesth Analg 2020;131:e40-1). How did COVID-19 rapidly reverse 20 years of progress in evidence-based sedation and ICU liberation? In patients with COVID-19 ARDS, tachypnea, excessive respiratory drive, and ventilator dyssynchronies are commonly observed and attributed to high dead space (due to pulmonary... You do not currently have access to this content.

ICU Liberation for critically ill children in Hong Kong.

ICU Liberation for critically ill children in Hong Kong.

Every child, every day, back to play: the PICUstars protocol - implementation of a nurse-led PICU liberation program

BackgroundAs admissions to paediatric intensive care units (PICU) rise and mortality rates decline, the focus is shifting from survival to quality of survivorship. There is paucity of internationally accepted guidelines to manage complications like over-sedation, delirium, and immobility in the paediatric setting. These have a strong adverse impact on PICU recovery including healthcare costs and long-term functional disability. The A2F bundle (ABCDEF), or ICU Liberation, was developed to operationalise the multiple evidence-based guidelines addressing ICU-related complications and has been shown to improve clinical outcomes and health-care related costs in adult studies. However, there is little data on the effect of ICU Liberation bundle implementation in PICU.MethodsPICU-STARS will be a single centre before-and-after after trial and implementation study. It is designed to evaluate if the multidimensional, nurse-led ICU Liberation model of care can be applied to the PICU and if it is successful in minimising PICU-related problems in a mixed quaternary PICU. In a prospective baseline measurement, the present practises of care in the PICU will be assessed in order to inform the adaptation and implementation of the PICU Liberation bundle. To assess feasibility, implementation outcomes, and intervention effectiveness, the implementation team will use the Consolidated Framework for Implementation Research (CIFR) and process assessment (mixed methods). The implementation process will be evaluated over time, with focus groups, interviews, questionnaires, and observations used to provide formative feedback. Over time, the barriers and enablers for successful implementation will be analysed, with recommendations based on “lessons learned.”All outcomes will be reported using standard descriptive statistics and analytical techniques, with appropriate allowance for patient differentials in severity and relevant characteristics.DiscussionThe results will inform the fine-tune of the Liberation bundle adaptation and implementation process. The expected primary output is a detailed adaptation and implementation guideline, including clinical resources (and investment) required, to adopt PICU-STARS in other children’s hospitals.Patient and public involvement statementThe authors thank the PICU education and Liberation Implementation team, and our patients and families for their inspiration and valuable comments on protocol drafts. Results will be made available to critical care survivors, their caregivers, relevant societies, and other researchers.Trial registrationACTRN, ACTRN382863. Registered 19/10/2021 - Retrospectively registered.Study statusrecruiting.

Encephalopathy and Delirium

Delirium occurs commonly in critically ill patients. ICU delirium is associated with increased short-term and long-term mortality, increased ICU length of stay, and long-term cognitive deficits in these patients. There are significant health-care costs associated with ICU delirium. Delirium is often overlooked in patients when assessed by clinicians based on clinical judgment alone. The use of a validated delirium assessment tool increases delirium detection rates in patients. ICU delirium is a multifactorial process. Nonmodifiable risk factors include age, dementia, prior coma, emergency surgery or trauma, and a high severity of illness. Modifiable risk factors include benzodiazepine use and blood transfusions. There is no evidence to support the use of any pharmacologic agent for either the prevention or treatment of ICU delirium. Antipsychotics should only be used for symptom management in ICU patients with delirium, and then discontinued when no longer needed. The mainstay of delirium management should be a multi-component, non-pharmacologic strategy aimed at minimizing risk factors. One such multimodal strategy, the ABCDEF Bundle, can significantly decrease the incidence of ICU delirium. Additional research is needed to better understand the pathophysiology and management of ICU delirium. This review contains 5 figures, 7 tables, and 51 references Keywords: Delirium, Encephalopathy, Intensive Care, Outcomes, ABCDEF Bundle, ICU Liberation.

Encephalopathy and Delirium

Delirium occurs commonly in critically ill patients. ICU delirium is associated with increased short-term and long-term mortality, increased ICU length of stay, and long-term cognitive deficits in these patients. There are significant health-care costs associated with ICU delirium. Delirium is often overlooked in patients when assessed by clinicians based on clinical judgment alone. The use of a validated delirium assessment tool increases delirium detection rates in patients. ICU delirium is a multifactorial process. Nonmodifiable risk factors include age, dementia, prior coma, emergency surgery or trauma, and a high severity of illness. Modifiable risk factors include benzodiazepine use and blood transfusions. There is no evidence to support the use of any pharmacologic agent for either the prevention or treatment of ICU delirium. Antipsychotics should only be used for symptom management in ICU patients with delirium, and then discontinued when no longer needed. The mainstay of delirium management should be a multi-component, non-pharmacologic strategy aimed at minimizing risk factors. One such multimodal strategy, the ABCDEF Bundle, can significantly decrease the incidence of ICU delirium. Additional research is needed to better understand the pathophysiology and management of ICU delirium. This review contains 5 figures, 7 tables, and 51 references Keywords: Delirium, Encephalopathy, Intensive Care, Outcomes, ABCDEF Bundle, ICU Liberation.

Encephalopathy and Delirium

Delirium occurs commonly in critically ill patients. ICU delirium is associated with increased short-term and long-term mortality, increased ICU length of stay, and long-term cognitive deficits in these patients. There are significant health-care costs associated with ICU delirium. Delirium is often overlooked in patients when assessed by clinicians based on clinical judgment alone. The use of a validated delirium assessment tool increases delirium detection rates in patients. ICU delirium is a multifactorial process. Nonmodifiable risk factors include age, dementia, prior coma, emergency surgery or trauma, and a high severity of illness. Modifiable risk factors include benzodiazepine use and blood transfusions. There is no evidence to support the use of any pharmacologic agent for either the prevention or treatment of ICU delirium. Antipsychotics should only be used for symptom management in ICU patients with delirium, and then discontinued when no longer needed. The mainstay of delirium management should be a multi-component, non-pharmacologic strategy aimed at minimizing risk factors. One such multimodal strategy, the ABCDEF Bundle, can significantly decrease the incidence of ICU delirium. Additional research is needed to better understand the pathophysiology and management of ICU delirium. This review contains 5 figures, 7 tables, and 51 references Keywords: Delirium, Encephalopathy, Intensive Care, Outcomes, ABCDEF Bundle, ICU Liberation.

Encephalopathy and Delirium

Delirium occurs commonly in critically ill patients. ICU delirium is associated with increased short-term and long-term mortality, increased ICU length of stay, and long-term cognitive deficits in these patients. There are significant health-care costs associated with ICU delirium. Delirium is often overlooked in patients when assessed by clinicians based on clinical judgment alone. The use of a validated delirium assessment tool increases delirium detection rates in patients. ICU delirium is a multifactorial process. Nonmodifiable risk factors include age, dementia, prior coma, emergency surgery or trauma, and a high severity of illness. Modifiable risk factors include benzodiazepine use and blood transfusions. There is no evidence to support the use of any pharmacologic agent for either the prevention or treatment of ICU delirium. Antipsychotics should only be used for symptom management in ICU patients with delirium, and then discontinued when no longer needed. The mainstay of delirium management should be a multi-component, non-pharmacologic strategy aimed at minimizing risk factors. One such multimodal strategy, the ABCDEF Bundle, can significantly decrease the incidence of ICU delirium. Additional research is needed to better understand the pathophysiology and management of ICU delirium. This review contains 5 figures, 7 tables, and 51 references Keywords: Delirium, Encephalopathy, Intensive Care, Outcomes, ABCDEF Bundle, ICU Liberation.

ICU Survivorship-The Relationship of Delirium, Sedation, Dementia, and Acquired Weakness.

The advent of modern critical care medicine has revolutionized care of the critically ill patient in the last 50 years. The Society of Critical Care Medicine (was formed in recognition of the challenges and need for specialized treatment for these fragile patients. As the specialty has grown, it has achieved impressive scientific advances that have reduced mortality and saved lives. With those advances, however, came growing recognition that the burden of critical illness did not end at the doorstep of the hospital. Delirium, once thought to be a mere by-product of critical illness, was found to be an independent predictor of mortality, prolonged mechanical ventilation, and long-lasting cognitive impairment. Similarly, deep sedation and immobility, so often used to keep patients "comfortable" and to facilitate mechanical ventilation and recovery, worsen mortality and lead to the development of ICU-acquired weakness. The realization that these outcomes are inextricably linked to one another and how we manage our patients has helped us recognize the need for culture change. We, as a specialty, now understand that although celebrating the successes of survival, we now also have a duty to focus on those who survive their diseases. Led by initiatives such as the ICU Liberation Campaign of the Society of Critical Care Medicine, the natural progression of the field is now focused on getting patients back to their homes and lives unencumbered by disability and impairment. Much work remains to be done, but the futures of our most critically ill patients will continue to benefit if we leverage and build on the history of our first 50 years.

1116: PADgo! A Quality Improvement Intervention to Improve Measures of ICU Liberation

Kothari, Harsh1; Panicucci, Thomas2; Houston, Amanda2; Badheka, Aditya3; Cifra, Christina2 Author Information

Organizational Characteristics Associated With ICU Liberation (ABCDEF) Bundle Implementation by Adult ICUs in Michigan.

We surveyed ICU physician and nurse leaders, assessing their safety culture, ICU team collaboration, and work environment. Using logistic and linear regression models, we compared these organizational characteristics to bundle element implementation, and also compared physician and nurse leaders' perceptions about organizational characteristics and bundle implementation. All (n = 72) acute care hospitals with adult ICUs in Michigan. ICU physician and nurse leader pairs from each hospital's main ICU. We developed, pilot-tested, and deployed an electronic survey to all subjects over a 3 month period in 2016. Results from 73 surveys (28 physicians, 45 nurses, 60% hospital response rate) demonstrated significant variation in hospital and ICU size and type, organizational characteristics, and physician/nurse perceptions of ICU organization and bundle implementation. We found that a robust safety culture and collaborative work environment that uses checklists to facilitate team communication are strongly associated with bundle implementation. There is also a significant dose-response effect between safety culture, a collaborative work environment, and overall bundle implementation. We identified several specific ICU practices that can facilitate ABCDEF Bundle implementation. Our results can be used to develop effective bundle implementation strategies that leverage safety culture, interprofessional collaboration, and routine checklist use in ICUs to improve bundle implementation and performance.

Correction to: The ICU Liberation Bundle and Strategies for Implementation in Pediatrics

Table 2 of the original version of this article unfortunately was not formatted well, making it unclear for readers.

Strategies to Optimize ICU Liberation (A to F) Bundle Performance in Critically Ill Adults With Coronavirus Disease 2019.

The severe acute respiratory syndrome coronavirus 2 pandemic has stretched ICU resources in an unprecedented fashion and outstripped personal protective equipment supplies. The combination of a novel disease, resource limitations, and risks to medical personnel health have created new barriers to implementing the ICU Liberation ("A" for Assessment, Prevention, and Manage pain; "B" for Both Spontaneous Awakening Trials and Spontaneous Breathing Trials; "C" for Choice of Analgesia and Sedation; "D" for Delirium Assess, Prevent, and Manage; "E" for Early Mobility and Exercise; and "F" for Family Engagement and Empowerment [ABCDEF]) Bundle, a proven ICU care approach that reduces delirium, shortens mechanical ventilation duration, prevents post-ICU syndrome, and reduces healthcare costs. This narrative review acknowledges barriers and offers strategies to optimize Bundle performance in coronavirus disease 2019 patients requiring mechanical ventilation. The most relevant literature, media reports, and author experiences were assessed for inclusion in this narrative review including PubMed, national newspapers, and critical care/pharmacology textbooks. Uncertainty regarding coronavirus disease 2019 clinical course, shifts in attitude, and changes in routine behavior have hindered Bundle use. A domino effect results from: 1) changes to critical care hierarchy, priorities, and ICU team composition; 2) significant personal protective equipment shortages cause; 3) reduced/restricted physical bedside presence favoring; 4) increased depth of sedation and use of neuromuscular blockade; 5) which exacerbate drug shortages; and 6) which require prolonged use of limited ventilator resources. Other identified barriers include manageable knowledge deficits among non-ICU clinicians unfamiliar with the Bundle or among PICU specialists deploying pediatric-based Bundle approaches who are unfamiliar with adult medicine. Both groups have been enlisted to augment the adult ICU work force to meet demand. Strategies were identified to facilitate Bundle performance to liberate patients from the ICU. We acknowledge current challenges that interfere with comprehensive management of critically ill patients during the coronavirus disease 2019 pandemic. Rapid response to new circumstances precisely requires established safety mechanisms and protocols like the ABCDEF Bundle to increase ICU and ventilator capacity and help survivors maximize recovery from coronavirus disease 2019 as early as possible.

Coronavirus Disease 2019: Harnessing Healthy Fear via Knowledge, Attitudes, and Behavior.

Coronavirus Disease 2019: Harnessing Healthy Fear via Knowledge, Attitudes, and Behavior.

Best Practices for Conducting Interprofessional Team Rounds to Facilitate Performance of the ICU Liberation (ABCDEF) Bundle.

Daily ICU interprofessional team rounds, which incorporate the ICU Liberation ("A" for Assessment, Prevention, and Manage Pain; "B" for Both Spontaneous Awakening Trials and Spontaneous Breathing Trials; "C" for Choice of Analgesia and Sedation; "D" for Delirium Assess, Prevent, and Manage; "E" for Early Mobility and Exercise; "F" for Family Engagement and Empowerment [ABCDEF]) Bundle, support both the care coordination and regular provider communication necessary for Bundle execution. This article describes evidence-based practices for conducting effective interprofessional team rounds in the ICU to improve Bundle performance. Best practice synthesis. The authors, each extensively involved in the Society of Critical Care Medicine's ICU Liberation Campaign, reviewed the pertinent literature to identify how ICU interprofessional team rounds can be optimized to increase ICU Liberation adherence. Daily ICU interprofessional team rounds that foster ICU Liberation Bundle use support both care coordination and regular provider communication within and between teams. Evidence-based best practices for conducting effective interprofessional team rounds in the ICU include the optimal structure for ICU interprofessional team rounds; the importance of conducting rounds at patients' bedside; essential participants in rounds; the inclusion of ICU patients and their families in rounds-based discussions; and incorporation of the Bundle into the Electronic Health Record. Interprofessional team rounds in the ICU ideally employ communication strategies to foster inclusive and supportive behaviors consistent with interprofessional collaboration in the ICU. Patient care discussions during interprofessional team rounds benefit from being patient-centered and goal-oriented. Documentation of ICU Liberation Bundle elements in the Electronic Health Record may help facilitate team communication and decision-making. Conducting high-quality interprofessional team rounds in the ICU is a key strategy to support ICU Liberation Bundle use.

Common Challenges to Effective ABCDEF Bundle Implementation: The ICU Liberation Campaign Experience.

Although growing evidence supports the safety and effectiveness of the ABCDEF bundle (A, assess, prevent, and manage pain; B, both spontaneous awakening and spontaneous breathing trials; C, choice of analgesic and sedation; D, delirium: assess, prevent, and manage; E, early mobility and exercise; and F, family engagement and empowerment), intensive care unit providers often struggle with how to reliably and consistently incorporate this interprofessional, evidence-based intervention into everyday clinical practice. Recently, the Society of Critical Care Medicine completed the ICU Liberation ABCDEF Bundle Improvement Collaborative, a 20-month, nationwide, multicenter quality improvement initiative that formalized dissemination and implementation strategies and tracked key performance metrics to overcome barriers to ABCDEF bundle adoption. The purpose of this article is to discuss some of the most challenging implementation issues that Collaborative teams experienced, and to provide some practical advice from leading experts on ways to overcome these barriers.