ICU Liberation: How Pharmacists Can Champion Change and Improve Outcomes

As part of the multiprofessional team, pharmacists are logical champions of implementing and maintaining the ICU Liberation Bundle (A-F). The bundle has shown to improve short- and long-term outcomes for patients during their ICU stay and beyond. It can be applied to every patient, every day, by the full team. Pharmacists’ role in ICU Liberation has been demonstrated in numerous studies.^1-11 Key papers from the ICU Liberation Collaborative providing implementation and sustainability guidance have also highlighted the role of the ICU pharmacist.^12-14
 
Here we summarize how pharmacists can play an important role in the implementation and maintenance of each element of the ICU Liberation Bundle:
 

A Element: Assess, Prevent, and Manage Pain

• Educate staff on the importance of continual assessment and its relationship to medication administration and titration.
• Ensure that patient assessments are performed using a validated tool, such as the Numeric Pain Scale in patients who can verbalize or the Critical Care Pain Observation Tool or Behavioral Pain Scale in nonverbal patients.
• Aid in determining the optimal analgesic regimen for each patient considering the patient’s renal function, liver function, past medical history, and medications prior to admission.
• Facilitate transition to oral therapy and evaluate for indications to continue medications daily, especially during transitions of care, while minimizing side effects and opioid exposure where possible.
• Aid in developing evidence-based protocols to treat pain as part of the multiprofessional team.  

B Element: Both Spontaneous Awakening Trials (SATs) and Spontaneous Breathing Trials (SBTs)

• Assist in screening for and confirming the coordination of SATs and SBTs daily.
• Educate members of the multiprofessional team including physicians, nurses, advanced practice providers, and respiratory therapists on the importance of conducting and coordinating SATs and SBTs.
• Help in developing a protocol with inclusion and exclusion criteria for the SAT and SBT safety screen and conduction.  

C Element: Choice of Analgesia and Sedation

• Assess for appropriate level of arousal target daily using either the Richmond Agitation-Sedation Scale (RASS) or Sedation-Agitation Scale (SAS).
• Ensure coordination of the patient’s actual level of arousal with the targeted level of arousal and apply necessary interventions if needed.
• Recommend the use of light sedation with dexmedetomidine or propofol or no sedation as compared to benzodiazepine-based sedation.
• Ensure that the pharmacist can prescribe to maximize the safety and efficiency of pharmacologic regimens at sites with pharmacy collaborative practice agreements.
• Aid in developing evidence-based protocols to treat agitation as part of the multiprofessional team.  

D Element: Delirium: Assess, Prevent, and Manage

• Ensure that patient assessments are performed using a validated tool such as the Confusion Assessment Method for the ICU (CAM-ICU) or Intensive Care Delirium Screening Checklist (ICDSC).
• Review medication lists daily to minimize deliriogenic medications.
• Recommend nonpharmacologic strategies to prevent and treat delirium.
• Aid in developing evidence-based protocols to prevent and minimize delirium as part of the multiprofessional team.

E Element: Early Mobility and Exercise

• Evaluate the patient’s medication list daily to aid in minimizing sedating or deliriogenic medications that may preclude early mobility.
• Identify patients who are candidates for early mobility and recommend that the team consult physical and occupational therapy.
• Orchestrate the administration of nonopioid-based pain relievers to facilitate successful physical and occupational therapy patient experiences.
• Aid in developing evidence-based protocols to triage physical therapy among physical therapists, occupational therapists, nurses, and family based on the patient’s clinical status.  

F Element: Family Engagement and Empowerment

• Educate the patient and the the patient’s support system.
• Aid in incorporating family members into multiprofessional rounds.
• Assist in educating the patient and the patient’s family on the importance of using the ICU Liberation Bundle and the prevention of post-intensive care syndrome (PICS).

With the necessary knowledge, training, and support from the multiprofessional team, ICU pharmacists are ideally positioned to serve many important roles as part of ICU Liberation Bundle implementation and maintenance. Pharmacists’ roles go beyond the C element; they play a role in implementing and maintaining all parts of the ICU Liberation Bundle.
 
 
References

1. MacLaren R, Plamondon JM, Ramsay KB, Rocker GM, Patrick WD, Hall RI. A prospective evaluation of empiric versus protocol-based sedation and analgesia. Pharmacotherapy. 2000 Jun;20(6):662-672.
2. Stollings JL, Foss JJ, Ely EW, et al. Pharmacist leadership in ICU quality improvement: coordinating spontaneous awakening and breathing trials. Ann Pharmacother. 2015 Aug;49(8):883-891.
3. Lizza BD, Jagow B, Hensler D, et al. Impact of multiple daily clinical pharmacist-enforced assessments on time in target sedation range. J Pharm Pract. 2018 Oct;31(5):445-449.
4. Devlin JW, Marquis F, Riker RR, et al. Combined didactic and scenario-based education improves the ability of intensive care unit staff to recognize delirium at the bedside. Crit Care. 2008;12(1):R19.
5. Gesin G, Russell BB, Lin AP, Norton HJ, Evans SL, Devlin JW. Impact of a delirium screening tool and multifaceted education on nurses’ knowledge of delirium and ability to evaluate it correctly. Am J Crit Care. 2012 Jan;21(1):e1-11.
6. Swan JT. Decreasing inappropriate unable-to-assess ratings for the confusion assessment method for the intensive care unit. Am J Crit Care. 2014 Jan;23(1):60-69.
7. Marino J, Bucher D, Beach M, Yegneswaran B, Cooper B. Implementation of an intensive care unit delirium protocol: an interdisciplinary quality improvement project. Dimens Crit Care Nurs. 2015 Sep-Oct;34(5):273-284.
8. Stollings JL, Bloom SL, Wang L, Ely EW, Jackson JC, Sevin CM. Critical care pharmacists and medication management in an ICU recovery center. Ann Pharmacother. 2018 Aug;52(8):713-723.
9. Marshall J, Finn CA, Theodore AC. Impact of a clinical pharmacist-enforced intensive care unit sedation protocol on duration of mechanical ventilation and hospital stay. Crit Care Med. 2008 Feb;36(2):427-433.
10. Louzon P, Jennings H, Ali M, Kraisinger M. Impact of pharmacist management of pain, agitation, and delirium in the intensive care unit through participation in multidisciplinary bundle rounds.Am J Health Syst Pharm. 2017 Feb 15;74(4):253-262.
11. Barnes-Daly MA, Phillips G, Ely EW. Improving hospital survival and reducing brain dysfunction at seven California community hospitals: implementing PAD guidelines via the ABCDEF bundle in 6,064 patients. Crit Care Med. 2017 Feb;45(2):171-178.
12. 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.
13. Stollings JL, Devlin JW, Lin JC, Pun BT, Byrum D, Barr J. Best practices for conducting interprofessional team rounds to facilitate performance of the ICU Liberation (ABCDEF) Bundle. Crit Care Med. 2020 Apr;48(4):562-570.
14. Balas MC, Pun BT, Pasero C, et al. Common challenges to effective ABCDEF bundle implementation: the ICU Liberation Campaign experience. Crit Care Nurse. 2019 Feb;39(1):46-60.