New Study Showcases the Power of the ICU Liberation Bundle

At the 2024 Critical Care Congress, lead author Juliana Barr, MD, FCCM, outlined the results of the study, “Improving Outcomes in Mechanically Ventilated Adult ICU Patients Following Implementation of the ICU Liberation (ABCDEF) Bundle Across a Large Healthcare System,” which was published in the January 2024 issue of Critical Care Explorations.¹
 
Dr. Barr is a staff anesthesiologist and intensivist at the VA Palo Alto Health Care System in Palo Alto, California, and professor emerita in the Department of Anesthesiology, Perioperative, and Pain Medicine at the Stanford University School of Medicine.
 
The ICU Liberation Bundle consists of six elements labeled A through F that work synergistically to manage pain, avoid oversedation, reduce delirium, facilitate weaning from mechanical ventilation, achieve early mobilization, and increase patient and family engagement in care, all aimed at improving clinical outcomes and reducing healthcare costs for ICU patients. The bundle elements can be applied to every ICU patient every day:

• A: Assess, Prevent, and Manage Pain
• B: Both Spontaneous Awakening Trials (SATs) and Spontaneous Breathing Trials (SBTs)
• C: Choice of Analgesia and Sedation
• D: Delirium: Assess, Prevent, and Manage
• E: Early Mobility and Exercise
• F: Family Engagement and Empowerment

Implementation of the ICU Liberation Bundle was making strides worldwide until the COVID-19 pandemic hit, overwhelming ICUs, said Dr. Barr. “The pandemic really set the practice of critical care medicine back several decades, but it also specifically set bundle performance back,” she said. “COVID patients were so sick, and hospitals and ICUs were so overwhelmed that the practice of critical care medicine became a global exercise in disaster medicine, with few resources dedicated to performing the bundle.”^2,3
 
After the pandemic, many champions of the ICU Liberation Bundle retired, moved on, or left medicine altogether, Dr. Barr said. “For most ICUs, this created a brain drain and a loss of institutional knowledge about the ICU Liberation Bundle, because the people who left were the ones who had the bundle experience pre-pandemic.”

How the ICU Liberation Bundle Improves Patient Care

“The ICU Liberation Bundle takes an integrative approach to managing pain, sedation, and delirium in critically ill patients to facilitate ventilator weaning in mechanically ventilated patients, early mobilization of all ICU patients, and patient and family engagement,” Dr. Barr said during the Critical Care Congress session.
 
“Previous studies have shown that the ICU Liberation Bundle clearly works. It shortens ICU stays, decreases mortality rates, improves short and long-term patient outcomes, and saves millions of healthcare dollars.^4-9 But it needs strong buy-in, support, and the investment of resources from healthcare administrators”, Dr. Barr said.
 
In 2013, the 34-hospital Dignity Health System (now a part of CommonSpirit Health) began a multicenter, prospective, cohort observational study in hospitals in the Sacramento, California region. The goal was to fully implement the ICU Liberation Bundle in mechanically ventilated adult ICU patients in 11 ICUs across six community hospitals, with the ultimate goal of implementation across all adult ICUs in the system. Funding for the pilot study partially supported a study coordinator, a physical therapist, and a physician champion at each hospital.
 
The study found that comprehensive bundle implementation was associated with significant reductions in ICU LOS, mechanical ventilation duration, and long-term ICU stays for mechanically ventilated patients. Average ICU LOS decreased by 0.5 days, mechanical ventilation duration decreased by 0.6 days, and the percentage of patients with an ICU LOS longer than seven days decreased by 18%. There were also trends toward reduction in hospital LOS and in-hospital mortality, but these differences were not statistically significant.
 
Compliance with individual bundle elements varied. Performance of pain management protocols and SAT and SBT trials were high at baseline and remained high over time, and reintubation rates did not increase. Sedation assessments significantly increased, while the use of benzodiazepine infusions for sedation decreased. Delirium assessments increased, and delirium prevalence decreased. Early mobility and family engagement scores did not significantly change.
 
Over the next three years, several changes were made to facilitate systemwide bundle spread and sustainability. Full implementation of the ICU Liberation Bundle became a Dignity Health System priority at all hospitals. Leadership support for the bundle strengthened. Allocation of resources toward bundle implementation and sustainability efforts both increased. Bundle performance metrics were fully integrated into the electronic health record (EHR), along with standard bundle element order sets. Bundle performance and outcomes data were extracted in aggregate from the EHR to facilitate quality improvement efforts around the bundle.
 
Four years after the pilot study was completed, compliance with individual bundle elements still varied across all hospitals, with high compliance rates for sedation and delirium management protocols and use of non-benzodiazepines for sedation, intermediate compliance rates for SAT/SBT trials and family engagement, and the lowest compliance rates for early mobility. Systemwide, bundle performance exceeded that of the initial six study hospitals.

Overcoming Barriers to Bundle Implementation

"Lower compliance rates seen with SAT/SBT trials, early mobility efforts, and family engagement may reflect a greater need for interprofessional team communication, collaboration, and care coordination to execute these particular bundle elements,” Dr. Barr said. “Team communication is really essential to performing the bundle because the bundle is not a nursing bundle,” she explained. “ICU Liberation is a team sport, and the people on that team include everyone who directly cares for patients in the ICU. To improve and sustain bundle performance, hospitals also need systemwide IT support to fully integrate the bundle into the hospital’s EHR and to provide real-time data analytics to measure bundle performance. Otherwise, you don’t know what you don’t measure.”
 
“Perhaps most importantly, strong physician and administrative leadership support for the bundle is essential—making the bundle a healthcare system priority and allocating the necessary funds and resources to ensure success. If the ICU Liberation Bundle is not a top priority for hospital leadership, they’re unlikely to allocate the necessary resources to enable people to do the bundle at all, let alone well,” she said.
 
The Dignity Health System study is now the third large multicenter trial showing significant improvements in ICU patient outcomes following bundle implementation. What is unique about this study is that it quantifies the cumulative impact of the bundle on patient outcomes, significantly reducing patients’ ICU LOS and mechanical ventilation duration, and the number of patients with prolonged ICU stays.
 
In the wake of the pandemic, hospitals and ICUs continue to experience staffing shortages, EHR limitations, and increasing healthcare costs as barriers to implementing the bundle. But the clear benefits to implementing the ICU Liberation Bundle outweigh these costs. As Dr. Barr pointed out, the bundle has a dose-response effect; even partial bundle performance improves outcomes and reduces hospital costs.^4,5 Reducing ICU LOS also reduces hospital-acquired infections and other preventable harms in patients, which further reduces healthcare costs, improves hospital throughput, and improves long-term patient outcomes, with more ICU survivors able to be discharged home than to a skilled nursing or rehabilitation facility. This is the value proposition of ICU Liberation.
 
In Dr. Barr’s own 15-bed medical-surgical ICU, bundle implementation decreased ICU LOS an average of half a day, saving the hospital $5 million in one year. Previous studies have also shown significant cost savings following bundle implementation.^7-9
 
“The ICU Liberation Bundle is the only intervention universally applicable to all ICU patients. It is specifically designed to improve the health of critically ill patients, improving both their short-term and long-term outcomes. It’s about helping ICU patients to not only survive but thrive after a critical illness or injury,” Dr. Barr said. “ICU clinicians and leaders must partner with hospital and healthcare system executives to make the strong business case for ICU Liberation.”

Watch the session from the 2024 Critical Care Congress on SCCM’s YouTube channel.
 
 
References
 

1. Barr J, Downs B, Ferrell K, et al. Improving outcomes in mechanically ventilated adult ICU patients following implementation of the ICU Liberation (ABCDEF) Bundle across a large healthcare system. Crit Care Explor. 2024 Jan 19;6(1):e1001. https://doi.org/10.1097%2FCCE.0000000000001001
2. Morandi A, Piva S, Ely EW, et al. Worldwide survey of the "Assessing Pain, Both Spontaneous Awakening and Breathing Trials, Choice of Drugs, Delirium Monitoring/Management, Early Exercise/Mobility, and Family Empowerment" (ABCDEF) Bundle. Crit Care Med. 2017 Nov;45(11):e1111-e1122. https://doi.org/10.1097/CCM.0000000000002640
3. Liu K, Nakamura K, Katsukawa H, et al. Implementation of the ABCDEF Bundle for critically ill ICU patients during the COVID-19 pandemic: a multi-national 1-day point prevalence study. Front Med (Lausanne). 2021 Oct 28;8:735860. https://doi.org/10.3389/fmed.2021.735860
4. 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. https://doi.org/10.1097/CCM.0000000000003482
5. 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. https://doi.org/10.1097/CCM.0000000000002149
6. Balas MC, Vasilevskis EE, Olsen KM, et al. Effectiveness and safety of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle. Crit Care Med. 2014 May;42(5):1024-1036. https://doi.org/10.1097/CCM.0000000000000129
7. Hsieh SJ, Otusanya O, Gershengorn HB, et al. Staged implementation of awakening and breathing, coordination, delirium monitoring and management, and early mobilization bundle improves patient outcomes and reduces hospital costs. Crit Care Med. 2019 Jul;47(7):885-893. https://doi.org/10.1097/CCM.0000000000003765
8. Otusanya OT, Hsieh SJ, Gong MN, Gershengorn HB. Impact of ABCDE Bundle implementation in the intensive care unit on specific patient costs. J Intensive Care Med. 2022 Jun;37(6):833-841. https://doi.org/10.1177/08850666211031813
9. Fish JT, Baxa JT, Draheim RR, et al. Five-year outcomes after implementing a pain, agitation, and delirium protocol in a mixed intensive care unit. J Intensive Care Med. 2022 Aug;37(8):1060-1066. https://doi.org/10.1177/08850666211063404