ICU Liberation Bundle Implementation: Nurses Champion Change as Early Adopters

How can nurses champion change and improve outcomes by implementing the ICU Liberation Bundle (A-F)? As both a bedside critical care nurse and a remote quality nurse consultant, I have championed various system-wide quality initiatives. Critical care nurses already understand some of the challenges involved in implementing the ICU Liberation Bundle. Leadership support is required to ensure appropriate equipment, electronic tools, and personnel to empower the nurse’s role in this vital evidence-based practice. A supportive integrated workflow framework is also required to promote the coordination of a multiprofessional collaborative approach to allow nurses to deliver the patient-centered, evidence-based, and quality-driven care that improves their patient’s outcomes.
 
To champion change for improved implementation of the ICU Liberation Bundle, nurses must become early adopters and influencers of evidence-based practices. This role requires commitment to patient care and knowledge of the evidence-based practices embedded in the bundle. Nurses, who provide 24/7 critical care, must focus on advocacy for their patients’ best outcomes and long-term survival. To support complete bundle implementation, nurses must advocate for multiprofessional collaboration and proactively ensure the inclusion of appropriate team members to implement the bundle.
 

Nurses as Early Adopters and Influencers

Supportive leadership teams generally provide standardized multiprofessional education in their facility’s shared mental model of implementing the ICU Liberation Bundle. A shared mental model improves team performance by providing a shared understanding of the tasks to be accomplished by each team member.¹ Nurses who are early adopters may be supported by educators to be champions of the ICU Liberation Bundle initiative in their units. Nurses may facilitate daily workflows until bundle implementation is adopted into their unit culture. Nurse champions are supported in their role as multiprofessional collaborator by the facility’s shared mental model. Champions of change initially implement small tests of change to improve staff buy-in and unit adaptation. These tests should be conducted on the easiest patients first and then spread based on improvements and successes. Nurses best support sustainability of bundle implementation by facilitating monthly multiprofessional meetings to provide progress updates and allow the various disciplines to discuss concerns, barriers, and solutions.

Nurses Champions as Knowledge Workers of Evidence-Based A-F Elements

Nurses champions change and improve outcomes in ICU Liberation Bundle implementation as knowledge workers of evidence that supports the bundle elements.² These elements, when implemented individually and/or collectively, reduce delirium and improve pain management and long-term survival for vulnerable critical care patients. Nurses should be familiar with evidence that supports the bundle, such as that outlined in the 2018 “Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU”³ and the 2017 “Guidelines for Family-Centered Care in the Neonatal, Pediatric, and Adult ICU.”⁴ Nurses should be familiar with evidence that supports the bundle to improve patients’ quality and safety outcomes as to ventilation duration, ICU and hospital lengths of stay, and ICU and hospital mortality.⁵

• A Element: Assess, Prevent, and Manage Pain
  • The nurse incorporates a tiered approach to pain assessment, starting with patients self-reporting pain when possible, and possibly including assessment of behavioral changes. The nurse may also ask family members to identify pain behaviors or assume pain is present.
  • The nurse uses pain assessment tools such as the Critical-Care Pain Observation Tool (CPOT) and Numerical Rating Scale (NRS) to guide appropriate interventions.

• B Element: Both Spontaneous Awakening Trials (SATs) and Spontaneous Breathing Trials (SBTs)
  • The nurse manages ventilated patients without sedation to awaken them for the SAT.
  • If the patient passes the SAT, the nurse coordinates with a respiratory therapist to conduct the SBT.
• C Element: Choice of Analgesia and Sedation
  • The nurse uses the Richmond Agitation-Sedation Scale (RASS) or the Sedation-Agitation Scale (SAS).
  • The nurse optimizes and recommends choice of sedation and analgesia for both pharmacologic and nonpharmacologic interventions.
• D Element: Delirium: Assess, Prevent and Manage
  • The nurse recognizes that delirium is common in critically ill patients and contributes to prolonged hospitalizations, increased mortality, and long-term cognitive impairment.
  • The nurse screens for delirium with one of the two recommended validated tools: Confusion Assessment Method for the ICU (CAM-ICU).
  • The nurse prevents delirium when possible and manages it when it is present.
  • The nurse reviews patient medications with a pharmacist, if available, to reduce drug exposures and to consider toxins and the use of nonbenzodiazepine sedatives.
• E Element: Early Mobility and Exercise
  • The nurse engages each moment of daily routine toward patient outcomes.
  • The nurse understands the long-term effects of ICU-acquired weakness and its effect on patients’ long-term survival.
  • The nurse screens patients for mobility level and potential early mobility strategies, then, if needed, coordinates with physical therapy, occupational therapy, and mobility teams, if available, to achieve desired outcomes.
  • The nurse identifies any exclusion criteria and navigates any barriers to early mobility, such as inadequate staffing, tools, resources, and leadership.
• F Element: Family Engagement and Empowerment
  • The nurse cares for the family’s needs as well as the patient’s needs.
  • The nurse includes family members in patient care to better understand the patient and to help the family feel valuable as a resource for the patient both during and after the hospital stay.

Nurses Champion Change as Providers of 24/7 Critical Care

Because nurses are at the patient’s bedside 24/7, they use their assessment skills continuously to monitor even the slightest condition variability that might require immediate intervention through implementation of the ICU Liberation Bundle. Nurses who champion change must ask themselves throughout their shift, “Am I doing this well enough, to the best of my knowledge and for my patient’s well-being?” The positive correlation between nursing care and patients’ quality outcomes is best demonstrated through the lens of SCCM’s ICU Liberation Bundle implementations. Barnes-Daly et al conducted a study of over 6000 patients in seven California community hospitals and found that, for every 10% improvement in overall bundle compliance, patients experienced 15% improvement in survival and family interaction.⁶

24/7 Knowledge Workers Growing Smarter Together

Stollings et al describe the eight most frequently asked questions during ICU Liberation Bundle implementation and provide practical advice for improved compliance and future implementation.⁷ Following are teamwork and process improvement recommendations for each bundle element.

Elemental Q&A, Teamwork, and Process Improvement

A Element: The NRS has only mild positive correlation with the CPOT but the two scales measure different aspects of pain. The 1-10 NRS is used when a patient can self-report pain intensity. The CPOT is used when the clinician must positively or negatively observe pain-related behaviors in a noncommunicative patient.
 
B Element: SBTs are recommended only for patients meeting the following criteria: sponta­neous breathing, fraction of inspired oxygen (Fio₂) 50% or less, Sao₂ of 88% or greater, and positive end-expiratory pressure less than 7.5cm H₂O. Other exclusory criteria include scheduled procedures, active seizures, acute myocardial infarction within the past 24 hours, vasopressor use, and increased intercranial pressure.
 
C Element: Patients who remain calm after the SAT/SBT may not require any further IV sedation. If a patient becomes agitated and requires sedation, the pain-first approach of analgosedation should be tried. Opioid IV bolus is considered before opioid infusion to proceed, only if necessary, to sedative boluses before sedative infusions.
 
D Element: When ICU delirium is recognized, the patient’s medications are evaluated to identify the cause of delirium. Any sedatives, especially benzodiazepines, are stopped as soon as possible and titrated for light sedation as the cornerstone of ICU delirium management.
 
E Element: While multiple mobility tools are used for screening safety and mobility level, no studies have yet been conducted for any specific ICU populations. Further studies are recommended to evaluate and compare mobility tools.⁸.
 
F Element: Actively engaged families improve ICU patient outcomes through improved communication and trust among patients, families, and clinicians. Every opportunity should be taken to involve family members in patients’ daily care routines. When ICU Liberation Bundle elements are charted in the electronic health record, family engagement is documented.
 
Teamwork: Meaningful recognition sustains individual and group self-esteem and resilience, contributing to a healthy work environment and mitigating stress and burnout. Recognition of ICU team members who support ICU Liberation Bundle efforts is most meaningful when it is aligned with team members’ personal values and beliefs and when they are acknowledged for their contributions that make a difference in someone’s life.
 
Process Improvement: Continuous process improvement of ICU Liberation Bundle compliance is best ensured through the application of a structured checklist tool, a standardized rounding process, and detailed expectations of participants, including, at minimum, a registered nurse, a physician, and a pharmacist. The team should also include a respiratory therapist, nutritionist, social worker, and physical therapist, if available.⁹

Nurse Champions as Multiprofessional Collaborators

The nurse champion advocates for multiprofessional collaboration and may coordinate timing of staff presence to ensure follow-through. A team approach must be facilitated for best patient outcomes. SCCM’s recommended integrated workflow framework involves daily multiprofessional team rounding.  Assigned nurse mobility champions have proven beneficial as facilitators of early mobility, the one bundle element that nurses often cannot perform on their own. The nurse champion understands the importance of personal lifelong learning to maintain competency in the latest evidence-based practice and the importance of involvement in professional organizations that can inform and guide practice.

References

1. Boltey EM, Iwashyna TJ, Hyzy RC, Watson SR, Ross C, Costa DK. Ability to predict team members’ behaviors in ICU teams is associated with routine ABCDE implementation. J Crit Care. 2019 Jun;51:192-197.

2. Society of Critical Care Medicine. Improving patient care through the ICU Liberation Campaign. 2019. Accessed July 25, 2022. https://www.sccm.org/Communications/Critical-Connections/Archives/2019/Improving-Patient-Care-Through-the-ICU-Liberation

3. 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.

4. Davidson JE, Aslakson RA, Long AC, et al. Guidelines for family-centered care in the neonatal, pediatric, and adult ICU. Crit Care Med. 2017 Jan;45(1):103-128.

5. Pun BT, Balas MC, Barnes-Daly MA, et al. 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.

6. Barnes-Daly M, Phillips G, Ely E. Improving hospital survival and reducing brain dysfunction at 7 California community hospitals: implementing PAD guidelines via the ABCDEF bundle in 6,064 patients. Crit Care Med. 2017 Feb;45(2):171-178.

7. Stollings JL, Devlin JW, Pun BT, et al. Implementing the ABCDEF bundle: top 8 questions asked during the ICU Liberation ABCDEF Bundle Improvement Collaborative. Crit Care Nurse. 2019 Feb;39(1):36-45.

8. Bruce R, Forry C. Integrating a mobility champion in the intensive care unit. Dimens Crit Care Nurs. 2018 Jul/Aug;37(4):201-209.

9. Barnes-Daly MA, Pun BT, Harmon LA, et al. Improving health care for critically ill patients using an evidence-based collaborative approach to ABCDEF bundle dissemination and implementation. Worldviews Evid Based Nurs. 2018 Jun;15(3):206-216.