Pediatric ICU Team Success: Implementing the ICU Liberation Campaign

Yu Kawai, MD, knew that Mayo Clinic was the place he wanted to be. Dr. Kawai had just completed his fellowship in pediatric critical care medicine and was interviewing for his first job at Mayo in Rochester, Minnesota, USA. One of the main differentiators for Mayo—certainly in Dr. Kawai’s eyes—was its work with the Society of Critical Care Medicine’s (SCCM) Pediatric ICU (PICU) Liberation Collaborative.

“I was so excited when I interviewed at Mayo Clinic for my first job,” said Dr. Kawai, now a pediatric critical care specialist at Mayo. “When I heard about PICU Liberation and that Mayo was involved, that really was the key factor to me accepting the career opportunity at Mayo.”

The PICU Liberation Collaborative worked with hospital teams across the United States to optimize pain control and reduce sedative exposure and time on mechanical ventilation. Some of the goals for participating hospitals included:

• Increasing the length of time that patients were free of delirium and coma
• Engaging families to participate in the care and healing of their loved ones
• Enhancing teamwork through implementation of evidence-based care
• Creating partnerships with other institutions doing the same improvement work

In addition to the PICU Liberation Collaborative, SCCM ran an adult ICU Liberation Collaborative. The Mayo Clinic initially joined the PICU Liberation Collaborative as a way to implement best practices for the management of pain, extubation readiness, sedation, delirium, early mobilization, and family engagement. A team of crossfunctioning clinicians at Mayo implemented a bundle called the Bundle to Eliminate Delirium (BED) and a corresponding checklist that helped lead to improved patient outcomes as well as improvements in the culture of the delirium unit.

Approximately 50%–80% of mechanically ventilated patients experience delirium, as well as 20%–50% of patients with less severe illnesses. The result is prolonged hospitalization, increased mortality, and increased costs.

Beginning in March 2017, the checklist was used by nurses once per shift. During the first 12 weeks of its implementation, BED was found to have improved nursing confidence in recognition, assessment, management, and discussion of delirium during clinical rounds, as well as family education over the same 12 weeks in 2014, 2015, and 2016.

“We did see that our unit culture improved in terms of nurses’ ability to detect delirium symptoms and also to discuss delirium topics during rounds, and that was associated with decreased delirium prevalence in our unit,” Dr. Kawai said. “In the last 1.5 years, I’ve seen a tremendous improvement in unit culture and a multiprofessional, collaborative approach to patient care.”

The BED bundle and corresponding checklist were based on the ABCDEF bundle, the elements of which are:

• Assess, prevent, and manage pain
• Both spontaneous awakening trials and spontaneous breathing trials
• Choice of analgesia and sedation
• Delirium: assess, prevent, and manage
• Early mobility and exercise
• Family engagement and empowerment

The basic idea behind the ABCDEF bundle is that clinicians should first zoom out when it comes to a patient’s health and well-being; they should evaluate the entirety of the patient’s clinical status. From there, clinicians can zoom in on each element of the bundle to help determine the best type of treatment for each patient.

What helped make the Mayo Clinic’s adoption and implementation of its own bundle successful was that multiple departments and team members were involved, which meant that different people from different specialties and areas of focus could come together not only to brainstorm new ways to put patients first but also to implement new bundles.

“Allow them to develop the bundles that meet the needs of their workflow, and then come together to implement the ABCDEF bundle together,” Dr. Kawai recommended. “That truly worked well because the different disciplines feel responsible, accountable, and valued in the team approach to patient care.”

The bundle development had its challenges, most noticeably at its initial outset. “The most significant obstacle at the beginning was breaking down the silos, making sure the nurses talked to physicians, physicians talked to respiratory therapists, and so on and so on,” said Grace M. Arteaga, MD, pediatric clinical care specialist at Mayo. “Once those silos are broken and you establish a degree of trust and communication, that was the key to changing the culture.”

John C. Lin, MD, ICU Liberation Committee cochair and a physician at St. Louis Children’s Hospital, said the model implemented by Mayo is certainly one that can—and should—be implemented by other physicians, nurses, and medical teams at other hospitals around the country. “I was tremendously impressed with the work that Mayo Clinic did,” Dr. Lin said. “The bar has been set high.”