SCCM Pod-493: Bundle and Save: The Future of ICU Liberation

The Society of Critical Care Medicine's (SCCM) ICU Liberation Bundle (A-F) is unique because it can be applied to every patient, every day, by the full team. By fostering a holistic approach to treating patients and improving ICU team communication, the ICU Liberation Bundle has been proven in multiple studies to reduce: the likelihood of hospital death, delirium and coma days, physical restraint use, ICU readmissions, and discharges to rehabilitation facilities. Ludwig H. Lin, MD, was joined by Kristina A. Betters, MD, and Christopher Adams, PharmD, BCCCP, BCPS, FCCM, during the 2023 Critical Care Congress to discuss the future of ICU Liberation, including large-scale implementation, culture change, translation of existing tools, and implementation in resource-limited settings. This podcast is sponsored by Etiometry.

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Transcript:

This podcast is sponsored by Etiometry, where we believe high-acuity care teams deserve access to clinical intelligence to aid and care coordination. Developed within an ICU to meet clinicians’ most pressing needs, the platform’s customized visualization of hospital-specific protocols supports reducing length of stay and readmissions. See why some of the world’s top medical centers rely on Etiometry. Visit etiometry.com/getyourview.

Dr. Lin: Hello and welcome to the 2023 Critical Care Congress edition of the Society of Critical Care and Medicine podcast series. I’m your host, Dr. Ludwig Lin. Today, we’re getting together to discuss the topic, the future of the ICU Liberation Campaign.

Kristina Betters, MD is an assistant professor of pediatrics at Vanderbilt University in Nashville, Tennessee. Christopher Adams, PharmD, FCCM, is associate director of medical affairs for La Jolla Pharmaceuticals and is adjunct clinical faculty at Rutgers University in New Jersey. Kristina’s administrative and professional interests are in ICU Liberation. She cowrote the PANDEM guidelines, and she’s the upcoming cochair of the ICU Liberation Committee for SCCM. Chris has been an active member of the SCCM ICU Liberation Committee, and his interests in research include pain and agitation. Welcome to both of you and thank you so much for being here with us. Before we start, do you have any disclosures to report?

Dr. Adams: I have transitioned into the industry department, so I’m now the associate director of medical affairs for La Jolla Pharmaceuticals. None of this content overlaps with any of my responsibilities with that company.

Dr. Betters: I have a small amount of salary support on NIH grants as well but this will not be conflicting with what we’re discussing today.

Dr. Lin: Okay, good. Thank you. So let’s start talking. What are the upcoming priorities for the I ICU Liberation Committee?

Dr. Adams: I think I can start here. I believe we’re really focused on strengthening the ICU Liberation community, identifying our advocates, leaders, promoting champions within the field, and actually transitioning those champions into our trainers in order to build the sustainable community within the ICU Liberation charge. I think a lot of our practitioners recognize the importance of each component of the bundle, but I think our charges are to implement this as a whole with increased compliance over time. We’re really trying to listen to our members and utilize survey results and focus group data to help build out resources for ICUs to utilize and reinvigorate the bundle, especially post-pandemic. I think a lot of the pandemic structure created barriers to a lot of the implementation of each component, and I believe revisiting a lot of these, learning from the pandemic, and trying to get back online with a lot of our sites.

Dr. Lin: That is so true. I wanted to go off on a tangent and ask you about that because I feel like people sort of just threw a bunch of stuff at COVID patients and some of it definitely was not geared toward early ICU liberation and it was probably medically necessary but, yeah, how do you regroup? Do you feel like that set this paradigm backward? Or do you feel like everybody is pivoting back pretty readily? What are your thoughts about that?

Dr. Betters: I think that, from a staffing situation, and we in pediatrics weren’t hit as hard as the adults, we’re having our own form of a viral pandemic right now with other viruses going on in the PICU and we’re very, very busy. I think for a while, a lot of people were like, we can’t do the ICU Liberation Bundle because of staffing, and I’m starting to tell people, I’m not sure that staffing’s going to get better anytime soon so I think we have to start thinking out of the box of how we are going to do the A-through-F bundle in our patients with what we have in our resources right now because I think healthcare has changed. I think we’re in a different state right now. Waiting for more resources or staffing to be better is not the answer for our patients and thinking about how we can do this in a different way.

Dr. Lin: Wow, that’s the reality. You’re saying, let’s program with that in mind. What are some of the outside-the-box ideas that could work?

Dr. Betters: I think that’s a great question. I know in pediatrics, we’re having a major shortage of RTs right now. For us, when we mobilize patients, we do early mobility. Any patient who’s intubated, we usually have an RT at the bedside to be watching the endotracheal tube. Kids are at high risk for unplanned extubations. They have smaller tubes, less real estate, so one of the things we’ve done is trying to identify other individuals that can fill that role if we don’t have enough RT staffing. In my ICU, I’ve asked for the attendings, the fellows, and the nurse practitioners to be another set of hands if we don’t have an RT available. So trying to pivot and find solutions for situations like that, and I’m sure there are numerous other examples that people have in other units of how they’re doing it as well.

Dr. Lin: Yeah, that’s intense.

Dr. Adams: Yeah, and I think the ICUs that had formalized a lot of the ICU Liberation components prior to the pandemic need to revisit that, and especially with a lot of staff turnover, possibly incorporating retraining strategies, especially with new hires, possibly other disciplines now included in the ICU. I think it’s really important to protocolize this once again and let a lot of the new hires and possibly new faculty know how important it is, not only to understand the details of each component, but also to maintain compliance with the bundle as a whole.

Dr. Lin: Yes, I could totally see that as well. It sounded like what you had planned for this upcoming year was in part almost like a listening tour and getting feedback, but also getting ready for more education, and that education would be through almost like more ambassadors in the world of the ICU. Is that correct?

Dr. Adams: Yeah, I think that’s extremely important. As a committee, we have an amazing group of passionate people who’ve done incredible research in this area, but that’s not enough. I think we need to go local and reach out, especially to underserved populations, community hospitals with limited resources, and just spreading the word like podcasts like this and letting people know that we do have really amazing online resources that are free for even nonmembers of SCCM, really going out there, the printable materials, really strategies on how to incorporate this, how to measure compliance and how to follow up with training. I think that’s important, and really going out into the field and starting to train on site in person, now that a lot of the pandemic barriers have subsided.

Dr. Lin: That would be wonderful. Do you actually have the resources to do that?

Dr. Adams: Yeah. SCCM, if you go on the website, if you just Google “SCCM ICU Liberation,” there’s a lovely website. You can email iculiberation@sccm.org and really plan. You can do on-site teaching seminars. I’ve done a lot of these throughout the country. You actually go to the site. It’s more of a multidisciplinary organized class, generally two days. What we do is really want to train the leaders and champions at that institution who can become our trainers and really incorporate a lot of the compliance in the details of each bundle locally so we’re training people to have a sustainable process in order to implement each bundle and then track it. Use metrics in order to increase compliance and continue to train throughout the years of new staff and new developments in literature.

Dr. Betters: There’s a course that occurs at Vanderbilt every other year as well. There was one this past September, you can go and learn, and then you also have this option of having a course hosted at your institution or your region. Now that we have the new pediatric PANDEM guidelines that were recently released, we’re in a really exciting phase and we’re building out a peds ICU Liberation course as well, which we’re hoping will be a pre-session at Congress next year.

Dr. Lin: That sounds so exciting. These sound like really wonderful resources and I feel like this podcast has already been a win for being able to point this out to our listeners because I think there are a lot of people out there ready to do more. But you’ve got to start somewhere.

Dr. Adams: Hosting a program is a really good idea and I would really highlight the local SCCM chapters to be leaders on this. They could possibly reach out to me or whomever, or just the SCCM email, and really organize that. As a local chapter, you’re actually provided one free training program per year. So they can look into that and possibly do ICU Liberation. What we generally do as course providers is organize this in a fashion so we’re not necessarily going in there and lecturing at professionals. Culture is different at each site, so we’re really empowering them to teach a lot of this content and, of course, as a course provider, we’ll step in and do some of that content, especially if they don’t have resources to do that. Having those local people, having the respiratory therapists and the physical therapists actually provide that training, possibly even in a simulation fashion, locally at the ICU is extremely important and invaluable.

Dr. Lin: We’ve talked about some of the sort of philosophical educational goals. What are some of the new elements that we should talk about and make people aware of?

Dr. Betters: Well, there’s not a new letter being added quite yet. I feel like for a few years we’ve talked about G for good sleep, but the data are not quite there yet. I think that would be the next one if it happens, if we get more literature to support that. Some of the very detailed work that we’ve been doing recently is we sent out a survey, again focusing on barriers and how we can assist people. Then we had a focus group session here at Congress and we’re going to take all that information and try to determine what can we as a committee offer beyond the resources that we already have to help improve bundle implementation and compliance. Again, as I said, it’s an exciting time to be in pediatrics right now because we’re finally getting to catch up and build out some of the peds content that already exists in the adult world.

Dr. Lin: Cool. Chris, do you have anything to add to that?

Dr. Adams: Yeah, I think empowering the community to go online and check out what’s available for the online resources. The ICU Liberation Toolkit is there, and it’s really something that should be at least recognized that it’s there. Go through what’s available and start incorporating that. I think all practitioners know that each one of these individual components is necessary. Most people are practicing each one of these, but maybe not in its entirety. I think it’s really important to know how to organize this in a structured manner, so it’s standard of care on a daily basis in every patient. I think that’s something that people really need to recognize. Use a toolkit and identify ways to measure this in order to change outcomes. There’s not a lot of things we do every day in the ICU that changes morbidity and mortality as impactfully as ICU Liberation.

Dr. Lin: It sounds like people really should go check out the online resources. They could be really, really helpful.

Dr. Adams: Yeah, it’s really fantastic, and it gives you a lot of insights on how to organize this in a multidisciplinary fashion. I think everyone’s like, “Yes, of course, we do spontaneous breathing trials,” but do you pair that with spontaneous awakening trials, giving that patient more advantage on successfully completing their breathing trial? I think just stuff like that, and it sounds easy, but it’s really difficult to do from a resource perspective with coordinating nursing staff, with respiratory staff, with your medical staff, and being able to recognize that, especially on multidisciplinary rounds every morning.

Dr. Lin: I think nothing is easy when you have no idea what it should look like and when you don’t know how to go about suggesting it. I think having these resources is really good. Thank you guys for, number one, offering it and, number two, making sure that our listeners know that these are available resources. What are some of the long-term goals that you have?

Dr. Adams: I think our true long-term goal is to really have the A-to-F bundle in every ICU in a structured manner so it’s being done daily. In order to do that, I think everyone just really needs to sit down on their committee level, multidisciplinary fashion, and really roll this out as a whole. I’ve worked at various hospitals in the past where we’ll try to do this in a step-by-step process, starting with A, or maybe you start with D first. You’re identifying your weaknesses when primarily this should just be done possibly on a macro scale, rolled out all at once. We have a lot of leadership and champions at the bedside helping. This isn’t something we can just drop in the nurse’s lap and say, “Hey, we’re doing this now.” I think this is a very multidisciplinary task. It takes time, effort, training, education, and a lot of resources.

Dr. Lin: And everybody has to be engaged, so that totally makes sense.

Dr. Betters: I think, in my unit, one of the things we continue to struggle with is sustainability. The committee has worked for the past several years to create EHR builds with Cerner and Epic for ICU Liberation, and those are finally out. They’re not quite plug-and-play. I don’t think it’s as easy as we were hoping to incorporate them. But we’ve spent some time today at Congress talking about this. For listeners who weren’t able to come to Congress, if you go to our website, there’s some information there and there’s a built-in Epic foundation, which means if you have Epic at your institution, you can have it. You don’t have to pay extra, it’s part of the foundation build, but you need IT support to pull it over and do some mapping of variables. There are a lot of resources there. There are reports that you can get, compliance tools. It helps with flow sheets for documentation, but also for tracking compliance. Cerner has a similar build that’s out as well. As we think forward, once people are implementing, how do we sustain these changes and how do we keep this going? We all know, I mean, we’ve been there. It’s difficult. It’s something that everybody’s always working on. I hope that the EMR builds will be helpful for people in the long run.

Dr. Lin: Oh, my gosh, I think that’s such a great advancement because part of making something sustainable is you need to make it easy. You don’t want to add to somebody’s job because God knows it’s already hard enough to do the job of being a healthcare provider in the ICU. Having that be built in, how wonderful is that? Good job.

Dr. Adams: Yeah, and it’s really improved a lot of the rounding principles because all the information in Epic or Cerner is available to you in one screen, very organized, and it’s a great way to bring it up on rounds in kind of that checklist fashion.

Dr. Lin: So cool. Nice work. Thank you for mentioning that because let’s empower people to go to Epic and say, “Hey, I know we deserve this. I know we have it.”

Dr. Betters: Yeah, it’s here.

Dr. Lin: That’s great. Actually, this segues nicely. What are some of the harder elements in your experience for new ICUs to adapt and adopt in terms of ICU Liberation?

Dr. Adams: I go from personal experience; that’s the example I had brought up earlier. I think it’s when you have more moving parts generally with pairing the spontaneous awakening and spontaneous breathing trials, when you’re trying to pull other disciplines together to provide one organized intervention, it gets a little tougher. I think that just has to be done at a local level because it’s hard for us to define what works for every ICU. I’ve seen a lot of strategies fail, whether you’re trying to prepare someone for a spontaneous breathing trial, possibly by doing an awakening trial with an overnight shift and then transitioning. But the patient possibly needs more monitoring during that phase, and it’s probably not the best time during change of shift, right?

Sometimes people want that patient to be waking up while you’re on rounds evaluating the patient. But again, I think if you really delve into bedside practitioners’ responsibilities in the morning and what a lot of the nurses are doing in the morning, it’s pretty difficult to do, especially if you have a higher than 1:1 ratio of nurse to patient. You just have to find out that workflow and how it works, working with respiratory therapy and when they’re around and when they’re available, you’ve got to really try to plan a lot of this out where, maybe possibly with delirium, it’s a little more focused on implementing the scores, knowing the identification and how to manage it. I think a lot of these may be a little more streamlined, but some require a little more coordination.

Dr. Lin: It sounds like what you’re saying is having the additional resources at a local level will help tailor that.

Dr. Adams: Yeah. I think a lot of our trainers know this, they’ve done this. When they come to the site for those online training sessions, it really can provide a lot of insight for that so not everyone’s recreating the wheel.

Dr. Lin: Right.

Dr. Betters: It’s interesting. I think there are some differences in pediatrics, but some similarities. I think what I hear and what I experienced in the few ICUs I’ve worked in is that early mobility tends to be the difficult one for pediatrics because what’s your mobility goal in a pediatric patient? It depends on their age and their developmental level. For an infant, it may be their parents holding them. For an adolescent, it may be the same as an adult, you want to walk them down the hall. So building out those early mobility programs, they’re a little bit more complicated. There are a lot of concerns about safety. I’ve mentioned unplanned extubations and things like that. I hear a lot of people have difficulty with that. We always talk about this too. I think implementing everything together is important. You can’t start with early mobility if your patients are too sedated, right? If you haven’t done the C or the D and they’re delirious, early mobility’s not going to go well. I think the bundle works really well together in thinking through all of it because it all interplays with each other. I think a lot of people get caught up on that one in pediatrics.

Dr. Lin: Right. This actually leads me to another question I have for you about the PICU. There’s a lot of specialized information and knowledge that people should have to take care of children in different age categories, what to expect, what not to expect, what works. With the labor shortages and with the movement across the country of various staff, is it harder now to be ready in a PICU for things like ICU Liberation because maybe not necessarily everybody has the knowledge set already and they need to be trained further, or is that totally not true?

Dr. Betters: I think there’s some validity to that. We’ll have travel nurses come in and their orientation is very short and they may be experienced nurses but they come to us and we use the pCAM or the psCAM for delirium screening, but they may have been somewhere that did the CAPD before. There are two tools that we recommend in pediatrics that are sensitive, specific, and very reliable. Working through that because they don’t get this long orientation, and how do you overcome things like that? One thing we did recently was change our delirium charting flow sheets to have a bunch of information on how to do the actual delirium screening in the EMR.

Dr. Lin: Perfect. So smart.

Dr. Betters: In Epic, you have the row information and helping walk them through it because we need in-the-moment education because even though we do a delirium talk once or twice a year for all the nursing staff, they might not have worked here six months ago when we gave that talk so, again, I think trying to think out of the box of how we can make things sustainable in the setting that we have right now.

Dr. Lin: Having those prompts, smart. Have you tried that? Does that work for getting people up to speed faster?

Dr. Betters: Yeah, I think so. I also think we’re in a different generation, different education. I think what we used traditionally maybe isn’t working, so thinking through some in-the-moment stuff and other resources; it’s helped us with our delirium screening in our unit for sure when we made those EMR changes. We try and do multimodal education too. I would say that everything that I think is helpful is protocolizing things. I don’t know if you feel the same way on the adult side but I think making some protocols, like having an early mobility protocol that exists that people can reference so when they’re coming in, newer staff, you can show them that.

Dr. Adams: Yeah. A lot of this is available on the website as well and that encourages a lot of the practitioners and enables them. I think just coming off that E part, early mobility, a lot of people get deterred from that one because they immediately think that they need an assigned physical therapist in their ICU. I think from possibly a community ICU, which most are, they probably don’t have those resources. I know, at least in my history, our physical therapy staff is pretty overloaded, to say the least. I think, if you do host a course, it comes with the textbook and it comes with a lot of instructional training and activities on what the bedside nurse can offer for early mobility. So it’s not necessarily dependent upon auxiliary staff. It’s the small, simple things that we can do at the bedside, that kind of thing that I think impacts culture and change.

Dr. Lin: Wonderful. You guys are so great because you’re helping me segue to the next question. What are your suggestions and advice for people trying to change culture to get this started and to have it gain hold and become sustainable?

Dr. Betters: I have a joke about this. Culture change is hard. My joke is, if you do anything for 18 to 24 months, people forget that you didn’t always do it. So if you just hold tight, it’s hard, you try and push forward and share your wins, and then you get a couple years down the line and everybody’s like, “Oh, I didn’t remember we used to not have an early mobility protocol. I thought this is how we always did things here.”

Dr. Lin: I like it. I’ll ask them.

Dr. Betters: I’m being facetious but in all actuality, I think, give yourself grace. These changes are hard. It takes time, and I think you need the wins. You need to share the wins to gain support in your unit. I think at the end of the day, everybody wants to do the best thing for the patient, and people are busy and you’re adding some workload and taking that into consideration that everybody’s working very, very hard. So showing them how they’re impacting patient care, that is with real personal stories of patients, I think that is how you gain support.

Dr. Adams: Yeah, and you just absolutely need buy-in from leadership, and that goes all the way up to the C-suite. I think really pulling in all that, just to maximize your resources and not stop that inertia because anyone who’s hung out in an ICU for greater than 10, 20 years, we all know. There’s that old saying, at least where I came from, everything in the hospital moves at glacier speed, right? Because it’s hard to change culture, and people are set in their ways, and we were all trained a little differently depending on where we came from. I really do think it’s important to spread a lot of that information and a lot of the publications on implementing this bundle and what it’s been shown to do, so the actual outcomes and the survival benefit and where these patients go afterwards. I think once people really understand that and aren’t necessarily going straight to a pharmacologic agent to change something, these are things that we can just do by habit and protocolization, which is fantastic.

Dr. Lin: Yes. I’m so inspired by this. I think it’s very, very cool that this strategy, which we all know works, is now getting the support to go on a grassroots level for education. It sounds like you guys have resources on the website to help people model this behavior. You’ve empowered the healthcare workers by adding it to the major EHR programs, so this is all sounding like such good work. This is a good time for me to start wrapping this up, but I wanted to ask both of you, are there any topics that we haven’t covered that you really want to get across to our listeners?

Dr. Adams: Just really advocating taking advantage of those free online resources and reaching out to local champions. We’re all here to help facilitate anything for anyone out there. We really are trying to go global. A lot of these training sessions are happening in other countries now, so really trying to reach out and broaden our footprint there and help out underserved communities. A lot of this wouldn’t happen without pioneers coming out of Vanderbilt, Wes Ely, Brenda Pun, Pat Posa, other names like that, who inspired us. I’m sure we left out names, Joanna Stollings.

Dr. Betters: Heidi Smith.

Dr. Adams: Kudos to them for leading the way.

Dr. Betters: Yeah, I would just encourage people. I think every hospital system and every ICU has different barriers, but your barriers probably aren’t unique. Other people have gone through this and those of us who’ve implemented these things, we know it’s challenging. So reach out, ask a friend, ask them how they did it, how they overcame some of the barriers you’re experiencing. We’re here to help. I think ICU is a small community. I know the PICU is definitely an even smaller community. So ask people. That’s why having Congress in person is really nice because we can network and talk to each other. I’m always free to email, happy to chat, do virtual meetings with people who are trying to implement stuff.

Dr. Lin: Sounds great. Lean in basically.

Dr. Betters: Yes.

Dr. Lin: Thank you both so much for this. This concludes another edition of the Society of Critical Care Medicine Podcast series. For the podcast team, I’m Dr. Ludwig Lin. Thank you.

This podcast is sponsored by Etiometry, where we believe high-acuity care teams deserve access to clinical intelligence, to aid and care coordination. Developed within an ICU to meet clinicians’ most pressing needs, the platform’s customized visualization of hospital-specific protocols supports reducing length of stay and readmissions. See why some of the world’s top medical centers rely on Etiometry, visit etiometry.com.

Ludwig H. Lin, MD, is an intensivist and anesthesiologist at Sutter Hospitals in Northern California and is a consulting professor at Stanford University School of Medicine, where he teaches a seminar on the psychosocial and economic ramifications of critical illness.

This podcast was recorded during the Society of Critical Care Medicine’s 2023 Critical Care Congress. Access essential education online through Congress Digital. More than 120 sessions are available on an easy-to-use platform. Continuing education credit is also available. Some SCCM members receive complimentary access to Congress Digital. To learn more, visit sccm.org/congressdigital.

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