As a bedside nurse in the intensive care unit (ICU), I did not have much understanding of the financial impact my care was having on the patients and my hospital. I have since graduated with a masters degree in nursing as a clinical nurse specialist and achieved a doctorate of nursing practice. Since moving into an operations role nearly three years ago, I have seen the financial impacts of care to which I had been oblivious for the first part of my career. I ask myself: How do I advocate for the best patient care while balancing costs to ensure a financially healthy organization?
No one reading this will be shocked to hear that critical care is incredibly expensive and resource heavy in staffing, medications, and equipment. These aspects of care will never change. As leaders, we must find ways to utilize current resources to ensure that expectations of high-quality care delivery will be met. We must consider that team-based care is no longer a concept to simply talk about, but something that must be implemented now to effectively coordinate and move the patient along the continuum of health improvement.
This is where the
ICU Liberation Bundle (A-F) provides proven solutions that I have experienced firsthand. The ICU Liberation Bundle utilizes key foundational principles of care coordination to optimize the delivery of care to all critical care patients. None of the A-F elements are brand-new. What is unique is that, when bundled together, the elements of the ICU Liberation Bundle make up a coordinated successful approach to patient care and clinical outcomes. Implementation of the bundle will yield improved patient outcomes and transform staff culture.
Among the
most costly diagnoses for hospitals are septicemia, acute myocardial infarction, congestive heart failure, pneumonia, acute cerebrovascular disease, and respiratory failure.
1 Implementing the ICU Liberation Bundle can impact hospitals’ bottom line in part by fostering a culture that focuses on the continuum care for patients who are most likely to have these diagnoses—the sickest patients.
About the ICU Liberation Campaign
The ICU Liberation campaign is derived from the
2013 pain, agitation, and delirium guidelines, which were updated and expanded in 2018 to include immobility and sleep disruption.
2 Out of this patient-driven guideline came a framework—known as the ICU Liberation campaign—to assist the multiprofessional team in liberating ICU patients from analgesia, sedation, mechanical ventilation, and delirium, while encouraging mobility and family engagement. The aim is to avoid iatrogenic harm and move the patient out of the ICU as safely and quickly as possible.
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The A-F elements of the ICU Liberation Bundle can be applied to any patient in the ICU, regardless of reason for admission or need for mechanical ventilation. The bundle realigns the team to focus more on a patient’s symptoms than on the disease.
4
A
recent study of over 15,000 patients in 68 ICUs reported that proportional and complete bundle compliance demonstrated improved outcomes with significantly improved likelihood of survival; less coma, delirium, and physical restraint; increased extubation; avoidance of ICU readmission; and improved discharge home.
4 Complete bundle compliance on any given day was associated with increased likelihood of ICU and hospital discharge and significantly lower likelihood of mechanical ventilation, coma, delirium, and physical restraint on the following day. Patients who survived to hospital discharge had a 46% lower likelihood of ICU readmission.
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My Experience Implementing the ICU Liberation (A-F) Bundle
At our large healthcare system in the southeast United States, our institutional approach to the ICU Liberation Bundle implementation was twofold.
Phase one was a multisite pilot at three distinct ICUs at three different hospitals. Each hospital team was working toward implementing each element of the ICU Liberation Bundle and integrating data into the electronic health record. We limited the choice of pain, sedation, and delirium assessment scales to one to standardize processes. We created interprofessional education for all teammates, while also collaborating with our data analytics team to design and abstract documentation metrics for each element.
After successful implementation of the first phase, we then expanded across all nine hospitals and 16 ICUs. We learned some incredibly valuable lessons in the 18 months of this implement effort.
Early Mobility Is Key and It Is Everyone’s Goal
When we first started to implement the ICU Liberation Bundle, there were concerns about the resources needed from our physical therapy team as we worked to implement the early mobility element. It was important that all members of the team understood that early mobility is a goal shared by the full team. For example, nurses should be working to get a patient sitting in a chair. Delirium screening and timing of spontaneous awakening trials (SATs) and spontaneous breathing trials (SBTs) are all in the service of early mobility. Family engagement means loved ones can help get a patient moving during visits.
This team mentality centered around the goal of early mobility sparked everyone to think about their role in the patient’s full journey, beyond the ICU stay. When the entire ICU team, including the family, are focused on how their care can impact early mobility, it helps foster a cooperative and goal-orientated culture.
Avoid an All-or-Nothing Approach
When tracking compliance, we first used an all-or-nothing approach, meaning that, for the unit to receive credit for each element, it had to accurately document the assessment and performance of each opportunity. For example, if the patient had seven opportunities to have an SAT assessment, then the unit must document all seven times for the element to be counted as successful. The rationale for this was related to the capabilities of our abstraction process at the time. Unfortunately, the results were quite demoralizing to the staff. Their compliance for most of the elements was very low since they needed only one fallout to be considered noncompliant. This approach also did not allow the teams to identify how well they were performing on the metric and whether there was really a problem in that area.
With these lessons learned, we were excited to move toward a new direction—from seeking absolute perfection to focusing on opportunities of success. There is a big difference between 10% compliance and 95% compliance when performing a performance improvement assessment. See our results.
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Phase 2 Data Abstraction |
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We implemented a new data analytics model that allowed us to see all opportunities for each element and report compliance for that metric to each ICU. This allows that unit to see tangible evidence of where wins and opportunities for improvement really lie. Clinicians also have access to a report that identifies whether a specific shift or clinician is tied to the success or need for change. Our ICU leaders share this information with their nurses and clinicians on a weekly or daily basis, resulting in a resounding positive change. We also use this information in a system-wide competition, offering an incentive to the highest-performing ICU (all clinicians involved) each quarter with an annual recognition for highest-performing ICU and most improved.
ICU Liberation Can Help Cultivate Teamwork and Healthy Work Environments
As a system, we must be mindful that organizational factors are one of the major risk factors for burnout syndrome in clinicians, which includes increasing workload, lack of control over the working environment and community, and inadequate rewards.
5 As we are asking more from our staff, we as leaders must ensure that we are doing everything we can to provide a healthy work environment for them.
6 The
American Association of Critical-Care Nurses approaches this through effective communication and decision-making, true collaboration, appropriate staffing, and meaningful recognition.
6 The ICU Liberation campaign helps establish this culture of teamwork.
Find Low-Cost and No-Cost Solutions to Implement the ICU Liberation Bundle (A-F)
We need to continue to strive for daily SATs and SBTs on appropriate mechanically ventilated patients. No additional costs are associated with this, but it takes the coordinated approach among the bedside nurse, respiratory therapist, and intensivist while utilizing an evidence-based algorithm for daily sedation interruption.
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Delirium intervention should focus on reducing modifiable risk factors that will help improve cognition, sleep, mobility, hearing, and vision.
2 We set up a day shift and a night shift routine to include providing contact lenses or eyeglasses and hearing aids to those who needed them. At night, we attempted to turn off the lights and minimize noise. We switched baths from night shift to day shift to reduce sleep disruption.
Administrators worked with laboratory and radiology leaders to change the timing of daily and noncritical laboratory tests and examinations. These are now performed in the morning rather than mid- to late afternoon. This was a challenging change because physicians and surgeons requested laboratory test and examination results for morning rounds. However, these interruptions contributed to sleep disruption, so it was essential to work with all key parties on a solution.
Finally, we purchase quiet kits for patients from an outside vendor. The kits contained an eye mask, earplugs, education on delirium, and a patient/family journal.
How to Replicate Our Success
Leadership and administrative support are crucial to the viability of this campaign. We have the ability to assist with ensuring that the culture is there from the very beginning. Our system has made the ICU Liberation campaign its major critical care project for the past three years. Administrators and physician leaders should reach out to the Society of Critical Care Medicine (SCCM) to explore partnership opportunities. A wealth of resources are available at no cost. SCCM has been instrumental in our success as we have connected with them on multiple events and projects. The foundation of this work is time tested, dose responsive, evidence based and—at the end of day—the right thing for our patients.
Tips to Get Started with ICU Liberation
Reference
- Torio CM, Moore BJ. National inpatient hospital costs: the most expensive conditions by payer, 2013. Statistical Brief #204. Agency for Healthcare Research and Quality. Healthcare Cost and Utilization Project. May 2016. Accessed October 14, 2020. https://www.hcup-us.ahrq.gov/reports/statbriefs/sb204-Most-Expensive-Hospital-Conditions.pdf
- Devlin JW, Skrobik Y, Gélinas C, et al. Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Crit Care Med. 2018 Sep;46(9):e825-e873.
- Ely W. The ABCDEF Bundle: science and philosophy of how ICU Liberation serves patients and families. Crit Care Med. 2017 Feb;45(2):321-330.
- Pun BT, Balas MC, Barnes-Daly MA. Caring for critically ill patients with the ABCDEF Bundle: results of the ICU Liberation Collaborative in over 15,000 adults. Crit Care Med. 2019 Jan;47(1):3-14.
- Moss M, Good VS, Gozal D, Kleinpell R, Sessler CN. An official Critical Care Societies Collaborative statement: burnout syndrome in critical care healthcare professionals: a call for action. Chest. 2016 Jul;150(1):17-26.
- American Association of Critical-Care Nurses. AACN standards for establishing and sustaining healthy work environments. A Journey to Excellence, 2nd ed. Executive summary. 2016. Accessed October 14, 2020. https://www.aacn.org/~/media/aacn-website/nursing-excellence/healthy-work-environment/execsum.pdf?la=en
Suggested Reading
Kumar A, Gabbard E, Smith HAB, Vedral-Baron J, Aldrich M, Ely EW.
ICU liberation: optimizing quality and efficiency of critical care delivery. Becker’s Healthcare. December 21, 2017. Accessed October 14, 2020. https://www.beckershospitalreview.com/quality/icu-liberation-optimizing-quality-and-efficiency-of-critical-care-delivery.html
