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Improving Patient Care Through the ICU Liberation Campaign

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The word bundle appears more and more throughout society today, from telecommunications companies with bundled deals on cable and internet to car companies that include bonus items with the purchase of a car.

Patients may not want to think of their healthcare coverage as being in the same category as their cable provider, but a new study (Pun et al. Crit Care Med. 2019;47:3-14) by the Society of Critical Care Medicine’s (SCCM) ICU Liberation Collaborative found that, when it comes to caring for critically ill patients, implementation of a bundle approach showed significant and clinically meaningful improvements in outcomes.

The study, entitled “Caring for Critically Ill Patients with the ABCDEF Bundle: Results of the ICU Liberation Collaborative in Over 15,000 Adults,” examined the ICU Liberation ABCDEF bundle, which focuses on assessment and interventions that apply to all intensive care unit (ICU) patients. SCCM’s ICU Liberation initiative aims to liberate patients from the harmful effects of pain, agitation/sedation, delirium, immobility, and sleep disruption (PADIS) in the intensive care unit (ICU). By promoting the use of the ABCDEF bundle, the ICU Liberation initiative provides several resources focused on boosting the implementation of PADIS guideline recommendations into daily ICU practice.

The bundle is not geared toward one disease or condition; rather, it is geared toward symptoms such as pain and delirium that can apply to all ICU patients regardless of their diagnosis.

“Most of the previous ICU bundles have been disease- or infection-related,” said Brenda T. Pun, DNP, RN, FCCM, who was part of the collaborative’s steering committee faculty. “The ABCDEF bundle provides a helpful framework for staff to see the interrelatedness of both the processes and people involved in patient care activities. It forces us to turn from siloed care practices that have hindered teamwork and collaboration and have resulted in the inability of ICU systems to implement and sustain care measures and serves as a template to encourage our interprofessional staff to collaboratively organize and deliver care.”

Previous studies of the ABCDEF bundle were based on data from one hospital setting or within one system. The ICU Liberation Collaborative study, in contrast, included 15,225 patients from 68 ICUs across the country—2.5 times as many patients as the largest previous study.

“We all know that, while our ICUs are similar in many regards, they have many differences,” Ms. Pun said. “This diversity of settings allowed us to control for the impact of the specific hospital as well as for the type of setting. “The diversity helped to strengthen the results by controlling for variables that may have impacted the patient outcomes.”

“The ICU Liberation Collaborative found that the ABCDEF bundle results in significant and dose-related improvements in outcomes, including better survival, ICU readmission rates, and discharge distribution of ICU survivors,” Ms. Pun said. Implementation of the bundle was also associated with shorter durations of mechanical ventilation, delirium, coma, and physical restraint use. These findings were consistent with previous ABCDEF bundle studies.

Ms. Pun hopes the collaborative’s findings will help encourage other ICUs to implement the ABCDEF bundle. For those that do, she has several suggestions. The first step is to create a team that includes representatives from each field that will be involved in the bundle delivery, such as medicine, nursing, pharmacy, respiratory therapy, and rehabilitation.

“This core interprofessional work group will be the drivers behind moving the work of each element along,” Ms. Pun said. “They will provide key insights on identifying barriers and troubleshooting around them.”

It is also important to recruit senior leaders to the team. Senior leadership involvement helps the team advocate for resources and provides team recognition.

When introducing the bundle, Ms. Pun recommends focusing on the bundle as a whole rather than the individual elements. “Always keep that big picture in front of the team,” she said. “That way, when you are focused on finetuning one element of the bundle, the team does not lose sight that this one element is part of something bigger. Don’t forget to involve patients and their families in the bundle introduction. Also, track patient outcomes so you can provide regular feedback to your team.”

The collaborative members were excited by the study’s results. As Ms. Pun explained, though, there is more research to be done. “This paper helps emphasize why we should be doing the ABCDEF bundle because it is associated with improved patient outcomes,” she said. “Now we find ourselves in the place where we need to learn more about how to successfully implement this bundle in a way that is sustainable and adaptable over time as evidence changes.”

Learn more about the ICU Liberation initiative at