An interview with an ICU Liberation Collaborative Leader and Participant
Juliana Barr, MD, FCCM, is an associate professor of anesthesiology, perioperative, and pain medicine at the VA Palo Alto Health Care System in Palo Alto, California, USA. She has been helping the Society of Critical Care Medicine (SCCM) achieve its mission to improve patient care for more than a decade, most notably leading guideline development, serving on SCCM’s ICU Liberation, THRIVE, and Patient and Family committees, and participating and developing SCCM’s leading quality improvement collaboratives.
Dr. Barr was the lead author on the 2013 Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit. Her efforts on this guideline paved the way for the updated 2018 Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU (the PADIS guidelines).
She shared her experience implementing the PADIS guidelines and the ICU Liberation bundle (A-F), as well as the value she and her team gained from participating in the ICU Liberation Collaborative.
The ICU Liberation Collaborative was a quality improvement initiative from SCCM that brought together intensive care unit teams to share best practices, as well as pitfalls and challenges to implement the ICU Liberation bundle (A-F) in various projects.
The ICU Liberation Collaborative has ended, but you can learn more about the success of the project published in Critical Care Medicine and in Critical Connections.
SCCM offers many ways to support teams seeking to implement the PADIS guidelines and ICU Liberation bundle (A-F). Learn how you can get started today at sccm.org/ICULiberation.
Has your team implemented the PADIS guidelines and ICU Liberation bundle (A-F)?
Yes, in the ICU where I work—the VA Palo Alto Medical Surgical ICU—we have been working to continuously improve our implementation of the ICU Liberation bundle (A-F), which includes the main recommendations from the PADIS guidelines. Specifically, we’ve been working on optimizing pain, minimizing sedation, managing delirium more effectively using nonpharmacologic interventions, and promoting early mobility of patients, as well as promoting sleep in the ICU. We’ve been working on these goals over the last four years, since our ICU began its involvement in the ICU Liberation Collaborative in 2015.
I can say, speaking from my own personal and professional experience, in terms of how the bundle has impacted how we care for patients in our ICU, it’s really been a miraculous transformation in the short term.
How is ICU Liberation different from other guideline and bundle implementations?
Implementing the ICU Liberation bundle (A-F) and the PADIS guidelines transforms care rapidly.
These guidelines apply to every ICU patient, every day, which makes them unique compared to other guidelines, such as the Surviving Sepsis Guidelines, which apply only to specific subsets of critically ill patients.
Another critical difference is that guideline implementation and execution require ICU clinicians to take a more collaborative team-based approach that’s more patient- and family-centered. You can’t apply the guidelines well using a business-as-usual approach.
The third piece of it is that it really requires engagement by hospital executives. It’s a big bundle and it’s very complex. The ICU Liberation bundle (A-F) is really forcing a radical transformation in the practice of critical care. We certainly saw that in the ICU Liberation Initiative.
How has implementing the ICU Liberation bundle (A-F) changed your patient care?
I was caring for a patient recently in the ICU who had acute myeloid leukemia. He was very sick and he needed to be on a ventilator on very high concentrations of oxygen. Yet we were able to have him be wide awake and comfortable by minimizing the amount of sedatives and opioids we were giving him. And he gave me a big grin and a thumbs-up sign on ICU rounds. That’s a perfect example of how we’ve transformed care and how we’re taking better care of our patients. We also use opioids less frequently in the ICU; we’re using a more multimodal approach, which I think is particularly important given the spotlight and attention paid to the opioid crisis and how opioid consumption in the hospital is often the starting point for opioid addiction in patients after they’re discharged.
We also have a heightened awareness of delirium in our ICU. Nurses are now identifying delirium more consistently and confidently and are being more proactive about using nonpharmacologic evidence-based delirium management strategies such as reorientation, sleep promotion, and early mobility instead of reaching for an antipsychotic medication. We now know, from the recent MIND-USA study, that antipsychotic medication doesn’t effectively treat delirium, but it’s an easy, longstanding treatment modality that all of us have grown too accustomed to in managing patients with delirium.
We’re also using far fewer sedatives than we used to in our patients, with a significant shift away from benzodiazapines, which we know are not only more deliriogenic but are also associated with worse outcomes in critically ill patients. As a result, our sickest patients on mechanical ventilation are now awake.
How has implementing the ICU Liberation bundle (A-F) changed your family-centered care practice?
We’ve really been focusing on these best practices as a bundle. In our ICU, patient care is definitely more interdisciplinary and more patient centered. We now round in the patients’ rooms instead of standing outside talking about them, and we engage patients who are able to participate in discussions, as well as their family members, to develop a common shared understanding of what the goals of care are for each patient.
As a result of all of these bundle-related interventions, patients in our ICU are now more awake, more alert, more often pain free, and more interactive with their families and clinicians. Patients are able to more actively participate in their care and get better faster, and families are more engaged with ICU teams and playing a more proactive role in helping clinicians actually deliver care to patients.
For instance, family members are wonderful coaches for ventilator weaning and early mobility efforts. They’re much better than ICU clinicians—who tend to be total strangers—at reorienting their loved ones. They know who they are personally and they know details about their lives that we could never know. They are better at grounding their loved ones in reality. So families are really helping us do a better job in caring for their loved ones. The synergy between families and the ICU team is really paying off in terms of patients getting better faster and having better outcomes after they leave the ICU.
What is the return on investment benefit of implementing the ICU Liberation bundle (A-F)?
The Critical Care Medicine
article “Caring for Critically Ill Patients with the ABCDEF Bundle: Results of the ICU Liberation Collaborative in Over 15,000 Adults
” demonstrated a clear benefit when the ABCDEF bundle was applied. A variety of important ICU outcomes improved, including length of stay, duration of mechanical ventilation, restraint use, delirium prevalence, drug-induced comas, and mortality.
You don’t have to apply the bundle perfectly on every patient every day. It has what we like to call a dose-response effect, so even if your bundle performance is modest, you will see the benefit. But the better you apply the bundle and the more consistently you apply it in the care of all patients in the ICU, the greater your return on your investment.
So the ICU Liberation Initiative and the publications that are starting to come out of it are important in demonstrating the benefit of the bundle, but that alone is not sufficient.
The next step is to take those critical benefits and to show hospital and healthcare administrators, third-party payers, and government payers through Centers for Medicare and Medicaid Services (CMS) how much money the bundle can actually save in caring for these patients. And it’s not just about saving money while they’re in the ICU.
The net effect of our bundle implementation efforts in 2017 was to significantly reduce ICU and hospital length of stay, which translates into a $6 million net cost savings to our facility. So it’s a win-win-win-win for patients, hospitals, hospital administrators, and third-party payers.
We also know from the collaborative that once those patients leave the ICU and the hospital they’re less likely to be transferred to a skilled nursing or rehabilitation facility and they’re more likely to go home. That outcome is both more patient centered and more economically beneficial because we know that patients who are transferred to skilled nursing and rehabilitation facilities continue to incur significant healthcare costs, such as hospital readmission. We know that patients discharged to skilled nursing facilities are three times more likely to be readmitted to the hospital within three to six months after hospital discharge. And a huge target for CMS and third-party payers right now is to reduce hospital readmission rates.
So the benefits of the ICU Liberation bundle (A-F) travel far beyond the walls of ICUs, at least as far as ICU survivors go. And I think there needs to be more scrutiny about the economic benefits and the cost savings of implementing the bundle as well.
What was your experience participating in the ICU Liberation Collaborative?
As the lead author of the PAD guidelines, I’m embarrassed to admit that, prior to our participation in the ICU Liberation Collaborative, we were not doing a very good job of applying the bundle elements to every patient in our ICU.
Participating in the ICU Liberation Collaborative transformed the way that patients appear to me in my own ICU. About halfway through the collaborative, I went on administrative leave, and when I came back, I didn’t recognize where I was.
Patients who were on ventilators with tracheal tubes in their throats were walking around the ICU and running us over with walkers. They had this look of determination, like if you weren’t careful, they were going to go all the way to the parking lot, get in their cars, and go home. That was a 180-degree difference from how patients like those would have looked in our ICU just a few years ago. They would have been in drug-induced comas, flat on their back, in four-point restraints, and they would have been like that for weeks until they “got better.”
Throughout my entire career as an intensivist, which spans over a quarter-century, the definition of clinical success in the ICU has been the survival of patients in my care. In other words, if a patients left the ICU alive, I felt like I had done my job. But I now understand through my work with the PAD guidelines and the ICU Liberation Campaign that our traditional approaches can cause significant long-term negative impacts on patients’ ultimate outcomes. Under the old paradigm of care, if patients were lucky enough to get out of the ICU alive, they were far less likely to return to the quality of life they had before they became critically ill or injured.
The ICU Liberation Initiative represents a new paradigm of care. Participating in the ICU Liberation Initiative has been a game changer. It’s helped me humanize the care I deliver in the ICU. I think more longitudinally about the long-term impacts of my care and appreciate the importance of enabling patients to return to their lives after a critical illness or injury and not only to survive but to thrive. That’s what I now hope for every one of our patients, and I think that’s the great benefit and will be the great legacy of the ICU Liberation Initiative.
Your implementation does not have to be perfect right away. Small changes make a big difference.
No matter where you are in the process, SCCM can help you get to the next benchmark of quality improvement.
Visit sccm.org/ICULiberation for many ways to get started!