Countering COVID-19 Delirium with the ICU Liberation Bundle

Despite Challenges, ICU Liberation Bundle Key to Patient Outcomes

The ICU Liberation Bundle (formerly known as the A-F bundle) is more important than ever in the COVID-19 era. While the pandemic has changed much inside intensive care units (ICUs), the commitment to provide multiprofessional, high-quality care is unwavering.

Implementing the ICU Liberation Bundle may be challenging in the face of patient surges, complex care plans that are rapidly evolving, and safety measures meant to limit viral transmission. Family visitation is heavily restricted, multiprofessional bedside rounds are often limited or curtailed, and clinicians may spend less time at the physical bedside. All this may impact ICU Liberation Bundle elements related to proper pain and sedation assessments and coordination of awakening and breathing trials. Delirium may be even more pronounced or harder to manage in patients with COVID-19, especially without intense mobilization efforts and family support. Other challenges to ICU Liberation include drug shortages, staffing challenges, and communications issues, sometimes exasperated by having their faces obstructed by personal protective equipment (PPE).

Still, it is important to remember that the bundle is a pragmatic, evidenced-based strategy, validated in many different locations and disease states. “We must do what we know works. We have years of research that shows the ICU Liberation Bundle is effective. It has shown consistently the importance of attending not only to the patient’s immediate ICU needs but also to their ongoing physical, social, and neuropsychological needs,” said Jaspal Singh, MD, MS, MHA, FCCM, cochair of SCCM’s ICU Liberation Committee. 

Implementing the bundle has been shown to improve outcomes related to length of stay, duration of mechanical ventilation, restraint use, delirium incidence, drug-induced complications, and mortality. This blog post demonstrates that it does not need to be applied perfectly on every patient every day. Even if your bundle performance is modest, you can still improve a variety of important ICU outcomes.

Sharing information is a key to success. How is your ICU adapting to ensure bundle implementation? Share your experiences to help shape the future: 

• Take this survey to help SCCM better understand the landscape.

• Tweet your tips using the hashtag #ICULiberation.

“In the current COVID-19 reality, what creative things are our members doing to get to the core benefits of the bundle?” asked Dr. Singh. Meeting families through tele-health solutions, equipping therapists with PPE to engage in patient mobility, and creating team-based digital communication platforms are just a few ways ICU teams are adapting. “We know that the ICU Liberation Bundle is dose dependent. The more you do it, the better patient outcomes are, not only for the time spent in the ICU but also as patients journey beyond the ICU,” he added. “We are getting better at all elements of the bundle as we learn more about how to manage patients with COVID-19, but it does require ongoing learning, focused commitment, and applying new solutions. We will have to adapt the ICU Liberation work to the current pandemic, but the body of work should continue.”