The ICU Liberation Campaign from the Society of Critical Care Medicine (SCCM) has transformed critical care, but the COVID-19 pandemic and subsequent staffing challenges have posed major obstacles to maintaining progress. In this episode of the SCCM Podcast, host Ludwig H. Lin, MD, speaks with Juliana Barr, MD, FCCM, a key architect of the ICU Liberation Campaign. Dr. Barr was a lead author of the 2013 “Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit,” known as the PAD guidelines, an original cornerstone of the ICU Liberation Campaign (Barr J, et al. Crit Care Med. 2013;41:263-306). The guidelines’ recent 2025 update also addressed immobility and sleep disruption (Lewis K, et al. Crit Care Med. 2025;53:e711-e727).
Dr. Barr shares her personal journey from traditional ICU practices of heavy sedation and immobility to leading efforts that prioritize patient recovery, well-being, and post-ICU quality of life. She emphasizes how ICU Liberation reintroduced low-tech, high-impact interventions such as minimizing sedation, promoting early mobility, and engaging families—leading to better outcomes at lower costs. She cites the 2017 international survey by Morandi et al that demonstrated uneven but steady improvements in global ICU Liberation practices before the pandemic (Morandi A, et al. Crit Care Med. 2017;45:e1111-e1122).
Dr. Barr details the need for reeducation, multidisciplinary team engagement, and reworking electronic health record (EHR) systems to better support ICU Liberation goals.
Looking forward, Dr. Barr offers a "burning platform" approach, stressing that delaying ICU Liberation practices risks poorer patient outcomes. She advocates for cultural change, leadership engagement, real-time metrics visibility, and hospital-wide investment—including IT support to surface buried ICU Liberation Bundle data within EHRs.
By reframing ICU Liberation as a "team sport" and making best practices part of daily ICU culture, Dr. Barr believes institutions can reestablish the bundle’s momentum and reconnect healthcare teams to their core mission—helping patients return to meaningful lives after critical illness.
This conversation offers energizing, practical strategies for ICU teams at every stage of ICU Liberation implementation or reinvigoration.
Transcript:
Dr. Lin: Hello and welcome to the 2024 Congress edition of the Society of Critical Care Medicine podcast. I'm your host, Dr. Ludwig Lin. Today, I'm joined by Dr. Juliana Barr to talk about ICU liberation, transforming care, overcoming barriers, and ensuring resilience. There really is no one more ready to look at the big picture of the SCCM ICU liberation bundle than Dr. Barr. She is a professor emerita at Stanford University School of Medicine and a staff anesthesiologist and intensivist at the VA Palo Alto Medical Center. She was the lead author of the SCCM's 2013 clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit, is a founding member of the SCCM's ICU liberation campaign, and helped to create the ABCDEF bundle to translate these guidelines into practical clinical practice.
She is the past co-chair of the SCCM's ICU liberation committee. Do you have any conflicts to declare?
Dr. Barr: No, I have no financial interest in this, just my own passion.
Dr. Lin: That's what's important. Let's get to it. Maybe I could have you, since you were there at the very beginning of this, you were the creator, to you, how has the concept of the ABCDEF bundle changed over time?
Dr. Barr: You know, Ludwig, when I started out my career in critical care medicine over 30 years ago, the standard of practice for our sickest patients, particularly those on mechanical ventilation, was to put them in a drug-induced coma with or without restraint. Sometimes we even did chemical paralysis, and to keep them that way and not get them out of bed until they quote unquote got better. And for the first 20 years of my practice as an intensivist, the definition of success was that they survived their ICU stay in whatever condition they were discharged.
And I think my journey in helping to create the PAD guidelines and the ICU liberation campaign and the A through F bundle is the personal transformation that I have had the opportunity to go through, realizing, and this is a hard thing to admit, that for 20 years, I was directly responsible for hurting people and that there was a better way to do things that gave people a better chance of not only surviving but thriving after an ICU stay.
Because I have never met a patient or a family member who brought their loved one to an ICU and said yes to what we asked to do to them with the expectation that they were going to suffer. And if they did survive, that they would not be able to get back to their former life and that that was okay. I think everybody deep down inside, whether you ask them that directly or not, that's their hope.
They want their loved one to live, but they want their loved one to come back to them like they were before. And the way we were practicing critical care didn't give our patients the best chance of achieving that goal.
Dr. Lin: And you feel like we've made progress.
Dr. Barr: Yes. I think ICU liberation has been a game changer. It has given us not so much a new set of tools because really the bulk of what we do in ICU liberation is very low tech and kind of old school.
If you ask people who were practicing critical care four or five decades ago, they would tell you that they routinely got mechanically ventilated patients out of bed and nobody was sedated. And patients left the ICU walking and history got lost. And now we're rediscovering it again like some ancient civilization.
And what we're discovering is that if you optimize pain management and you use non-pharmacologic delirium management practices in the ICU, and I can talk about what that means more in a moment, but not reach for the Haldol every time somebody gets agitated and delirious, and you minimize sedation, that you can replicate that historical practice. And you can measurably improve patient outcomes both in the short term and the long term. And wait for it, you can do that and save a lot of money.
Dr. Lin: Sounds like a win-win.
Dr. Barr: It's the value proposition of ICU liberation. Better care, lower costs, better outcomes.
Dr. Lin: It's perfect. I think what it's really done for me is it's empowered everybody on each ICU multidisciplinary team to reset their expectations of how things should be and how things get done. So I think that's been great.
It's a platform that we can all look at and point to, a common language for us to be using in the ICU setting. So let's talk about what has changed recently for the bundle. I mean, I think this is probably the pink elephant in the room, or maybe it's not even the pink elephant, but how has the entire COVID-19 pandemic affected the practice and the adoption of the bundle in ICUs?
Dr. Barr: Yeah, great question and an unfortunate reality we're all experiencing. Let me just say that before the pandemic, as of 2017, when the ICU liberation campaign was launched, over the first five years of that, we were making modest but steady progress worldwide to improve the care of all ICU patients everywhere through ICU liberation. And the evidence for that is a survey by Miranda and colleagues who looked at bundle performance as a snapshot across multiple countries and ICUs.
And what they found was that we were doing a modest but ever better job of ICU liberation, although there was a fair amount of variability across the bundle elements. In other words, we weren't doing all the elements equally well. But in general, we were doing a good job of pain management in about 85% of our patients.
We were doing a good job of minimizing sedation and not using benzodiazepines in about 65% of our patients. And we were doing a good job of actively implementing delirium mitigation strategies in over half the patients. But then you look at SAT, SBT trials, and we were doing that at around 45, 50%.
And we were doing early mobility at a lot lower level, maybe 30%, and family engagement about 30%. So there was room for improvement. But if you looked at all the elements collectively, the tide was rising and the boats were rising with it.
So that was encouraging. And then the pandemic hit. And that brought, I think, everybody's bundle implementation efforts to a screeching halt.
And just because of the nature of the pandemic and what was at stake, we hunkered down in our foxhole and reverted to practices that harken back to the beginning of my career of deep sedation with or without paralysis in mechanically ventilated patients. And we took it a step further. They were sorely isolated.
The staff had a lot less contact with them. And then there was all this PPE between two people. And we didn't let families come in the ICU for safety reasons.
So, and then during the pandemic, somebody else conducted a similar worldwide survey of ICU liberation practices and found, not surprisingly, that compliance with all the bundle elements had dropped by more than half. And with family engagement being at an all-time low of only 16%. So now in the wake of the pandemic, which has really become more of an endemic phenomenon, how do we get back to where we were?
Because we have been transformed as a healthcare delivery process in ICUs irrefutably by the lingering effects of the pandemic. And why is that? Well, first and foremost, the pandemic caused what I termed the ICU brain drain.
A lot of people left the practice of critical care and not just nurses, doctors, APPs, pharmacists, respiratory therapists, physical therapists, the key players involved in implementing the various bundle elements together as a team. And in doing so, that left a staff shortage initially, and efforts to get back up to pre-pandemic staffing levels have been difficult because it takes time to train more nurses, and the ones that retired are not coming back. And so who have been the people to fill those gaps?
Two types. One is travelers. That was very big during the pandemic, and still a lot of hospitals use travelers.
Travelers, ironically, tend to be experienced ICU nurses, and many of them have previous ICU liberation experience from wherever they came from. But they're also there for the short term. They have no institutional investment or buy-in into improving ICU liberation implementation efforts at the facility that they're working, and they're on short-term contracts, and then they leave, and they're gone.
So that doesn't help us work together to move forward. The other cohort that gets hired to fill those vacancies, and I'm focusing on the nursing side, but this is true in all the other disciplines I mentioned, is hiring new grads, people with less than two years of experience as a nurse with no experience in critical care. And to make it worse, those people just out of nursing school got their training, or pharmacy school, or RT school during the pandemic, where their direct patient contact was severely reduced.
A lot of their learning was virtual. There wasn't the in-person mentoring that those disciplines benefit from, and that created a very different healthcare worker in the ICU. And so now we have this large and growing cohort of people who are totally naive about ICU liberation.
They don't know anything about it, but they're overwhelmed. They're just trying to get through their day. Time is their most precious resource.
The EHR is the villain, because they spend most of their time charting. And the last thing they want to hear is for somebody to say to them, well, now you have to start charting this new metric you've never heard of before, because they didn't teach it in school, called the CAM ICU, or the RAS sedation assessment tool, or the CPOT pain tool. Like, what is that?
It sounds like some foreign language of alphabet soup. So that's stressful to them, because now they're being asked to learn these new skills that are truly foreign to them. And then they're asked to be doing things like, well, we want to have you stop all their sedation at oh, dark 30 in the morning, so that the patient can wake up in time for the respiratory therapist to come and do a spontaneous breathing trial.
Well, A, that's terrifying to a new nurse, alone on the night shift to turn the sedatives and the opioids off and wonder what's going to happen next. So oftentimes, restraints are applied at that point, preemptively. And the patient now wakes up and finds themselves in the restraints and freaks out.
So that often sets back getting to an SBT trial. But even if that doesn't happen and they pass their SAT trial, now the nurse is waiting for that RT that has competing duties to show up at the bedside in a timely fashion to start the SBT trial. And if they aren't immediately available, that nurse is likely to just turn the sedation back on and they never get to an SBT trial.
So that's a problem. And similarly, the last thing an inexperienced nurse hears is, okay, we're going to ask you to get this intubated patient out of bed and don't let any of the tubes fall out. So we need to reeducate.
More importantly, we need to support our staff, particularly the nurses at the bedside, to not only learn how to ICU liberation well and safely and consistently, but also let them know that this isn't a nursing initiative. It's a team sport. And we need to engage all the stakeholders in that process so that people feel supported and that they're doing all of these elements together.
Dr. Lin: Yes, that is such a good summary. Not the happiest, but a very accurate summary of what's happened. And you make me think, you know, the reason the bundles was succeeding in the first place was that it indeed took a village.
It took everybody in the ICU and the administration, really, to be invested in it, to buy into it, and to give it that support. And what I'm hearing from you is that especially with the staff that we have now in the ICU who are more junior, there are fewer of them, that maybe getting that person power to them, to help them with the various activities involved in the bundle is even harder. So how do you see a path forward for us?
What is it going to take to get back on track and make this even thrive more?
Dr. Barr: I think for people who understand the value of ICU liberation and the A through F bundle, that we need to take responsibility for making the value proposition relevant to hospital administrators and to create a burning platform for our clinical stakeholders to understand what exactly is at risk here if we don't do ICU liberation.
Dr. Lin: Can you elaborate on that, a burning platform?
Dr. Barr: Yeah. So a burning platform is a concept of explaining to people that the house is on fire and you have to get out or you may not survive. And the analogy here being these antiquated practices of deep sedation and immobility and prolonged mechanical ventilation are, in fact, the house fire.
There may not be smoke in the room, but we have to act, and we have to act expeditiously. We can't wait a week to start applying ICU liberation to a like that. We need to do it the day they come to the ICU to minimize sedation, optimize pain management, promote sleep, bring the family into the bedside and keep their head on straight so that they don't get confused and delirious.
Don't apply restraints. Those are things that we can start doing on day zero and do them every day.
Dr. Lin: Who are the people who need to hear this, who need to see this data?
Dr. Barr: I think everybody who has a stake in the care of critically ill patients needs to see that data. And who are those people? So as I said earlier, they're team members that are directly involved in bundle implementation.
So not only the bedside nurse and the ICU physician or the APP, the nurse practitioner, PA in the ICU, but also the ICU pharmacist, the respiratory therapist, and the physical therapist. Those are the key players that are involved in implementing all the bundle elements. Their engagement may vary between bundle elements, but they all play an important role.
But in addition, ICU leadership needs to make it a priority with their staff. And who are those people? It's the ICU medical director and the nurse manager, but it's also the senior nurses.
We need to empower the senior nurses to be role models and using train the trainer models to train the junior nurses and say, this is our practice. This is why we're doing this. This is good for patients.
You're helping patients because nobody goes into healthcare to hurt any, right? So we need to speak to what's important to people who come and agree to work at an ICU setting. And we need to integrate ICU liberation into the daily workflow.
We need to make it easy to do ICU liberation and hard not to. So what does that look like? ICU liberation needs to be on everybody's mess board.
It needs to be part of every daily huddle. It needs to be part of flow sheets in the EHR that are transparent and in real time and have green lights and red lights about the work that's been completed and the work that has not. So that at a glance, somebody like a charge nurse can say, oh, we haven't gotten bed one, three, and five up today.
I better go and see what's needed to help that bedside nurse mobilize those patients. We need providers to be able to see who aren't 24 7 in the ICU. We need the attendings to be able to look at a patient who's been on sedatives for a week and see where their RAS score has been.
Are they really minus 2, minus 3 or at night? Are they mysteriously ending up as minus 4s and minus 5s? And then when the sun comes up and the SAT trial goes on and the rest of the day, they're at a lighter level of sedation.
So I think those are opportunities that the EHR, when leveraged correctly, can help inform us make better decisions. But I think EHRs have to evolve. I think they were historically designed as billing and documentation tools, and they need to move to the next level of becoming decision support and quality improvement tools.
And part of that includes being able to extract aggregated de-identified data out to measure your bundle performance and compare that against bundle-related outcomes and gold standard ICU outcomes like length of stay and mechanical ventilation. People don't know what they don't measure, and they need to be able to see the data in front of them. And I'm not talking about quarterly reports that you present only to the front office.
I'm talking about what we call potty press and putting weekly graphs of ICU metrics up in the bathrooms and the break rooms where people can see them, and they can see the threshold goal that they're working towards. And if you accept that 80% compliance is the definition of an effective clinical practice, and you set that bar at 80%, all our mechanically ventilated patients are at least going to have the opportunity to have an SAT-SBT trial every day. They may not pass them every day, but that doesn't mean we failed.
It means at least we tried. And to say we want to get to 80% compliance on that, we want to get to 80% on maximizing the mobility of every patient appropriately every day. We want to get to 80% on family engagement on rounds, whether they show up in person or virtually, or we define family engagement as having triggers for regular family conferences that are interdisciplinary and not uniquely physician family only.
So those, we have to make it part of the daily culture. ICU liberation is like the mom's apple pie of critical care medicine. It's just the right thing to do, and it's good for our patients.
And I would take that a step further, and I would challenge you to say it's good for burnout, because it helps people get back to what they came to healthcare for, which is to help people. And burnout kills empathy. So if you're burned out and overworked, and there's this big disconnect between ICU liberation and your daily workflow, and nobody has helped you make that a priority intellectually, emotionally, or physically, then you're just going to look at that as another task that's getting you in the way of completing your work every day.
But I would argue that people who have successfully done ICU liberation truly is a team sport, not a nursing initiative, not a pharmacy initiative, but an interprofessional team sport, where they're rounding at the bedside every day. They're using tools to facilitate interprofessional communication, like goal sheets and scripts that are bundle-centric. They're looking at the EHR in real time and discussing, oh, gee, yesterday he wasn't CAM positive, now he is.
Why is that? Are we doing the 10 best practices to prevent delirium in this case? Oh, the family's left town over the weekend, and they're not coming back for a week, and that's when he became delirious, when they stopped being at the bedside.
That's the kind of culture we want to create, where it's just part of the conversation. It becomes the root of our language around which we talk about patients in the ICU.
Dr. Lin: It's so true. And I think the times I've seen people really believe in the bundle and really talk about it on a daily basis, it's a win. Everybody likes to do things right.
So when this, like you said, is part of the culture, people get excited about doing it correctly. And also, there's a reason people like you are advocates for it. It actually achieves results.
So when people have good outcomes, it makes it even more exciting to continue the work. I wanted to ask you more about the EHR components of this, because like you said, that seems like a really good way to make it easier for us to work with the bundle. And it's not necessarily easy to do it, even though EHRs have that power easily.
So how can we all advocate for that to happen?
Dr. Barr: Right. Well, even though the metrics reside in Epic and Cerner, from our needs assessment survey that the ICU Liberation Committee conducted over the last two years, we've discovered that many people don't even know they're in there. And the ones that know they're in there can't quote, get to them.
And the problem behind that is that the way these systems have been designed is that they're by definition customizable, because that's what hospitals and healthcare systems have asked for. We want to make this uniquely ours. And there's a saying, if you've seen one Epic or Cerner system, you've seen one Epic or Cerner system.
And that has created an Achilles heel for standardizing anything in an EHR beyond basic vital signs. So they're in there. They're just like buried treasure.
So who gets to get the shovel to get the treasure up to the surface so that you can benefit from it? And that requires local IT help. And IT resources are a scarce resource.
ICU Liberation is typically not on their scorecard or their list of things to do, which is an arm long. And that's where taking that ask to the front office and saying, we want you to give us the resources we need and make ICU Liberation a priority. And that one of the top resources that we need is IT support.
We need other things, but first and foremost, we need IT support. Because until you get those metrics where everybody can see them every day, and until you can pull pooled metrics out and measure your performance and see how far you've come and how far you've yet to go, we're not going to make it very far because you don't know what you don't know.
Dr. Lin: Right. That's an easy thing for IT people to do. Difficult for the rest of us.
And that sounds like it should be a top action item for all of us. That sounds like a top tip. And I wanted to ask you about what the rest of your top tips are for ICUs looking to either implement or to improve their work with the bundle.
Dr. Barr: Unfortunately, the bundle is a journey of a thousand steps. And sometimes it's hard to see that you've made progress. But I tell people not to think about implementing the bundle in some sort of sequence.
Like this year, we're going to tackle pain management, the AA element. The next year we're going to do SAT, SBT trials. And the year after that, we're going to tackle sedation, et cetera, et cetera, et cetera.
The benefit of the bundle is only fully realized when you do everything at once. So you have to take a parallel implementation approach to all the bundle elements. But you also need to start with perfecting the skillset of the bedside nurses to perform the pain, sedation, and delirium assessments.
Because those assessments are performed 99.9% of the time by the nursing staff, not pharmacists, RTs, or physicians. But we can have a different discussion about why that is. But for now, that's the reality.
So we want to make sure that those frontline staff are doing it consistently and reliably. And there's arguably a lot of iterator variability of those metrics. And so what you end up with is those assessments form the foundation for everything else you're going to do around the bundle for every patient.
So it's garbage in, garbage out. If the nurses don't know how to do a CAM-ICU assessment correctly, and so they're constantly writing unable to assess, it's hard for you to know whether the patient's delirious or not, let alone whether you're making headway to make them not delirious or preventing delirium, as an example. Same thing with the RAS.
If the nurse doesn't know how to do the RAS correctly, and they're always charting minus two, because it says in the orders, thou shalt keep the patient between zero and minus two. And so they're like, okay, minus two looks good. But in fact, the patient's minus four, minus five, and unresponsive to painful stimuli, that's a problem.
You're not making good decisions if you have bad data. And so the assessments form the foundation of the house. The framing and the walls of the house are really the protocols and order sets that enable people to do the right thing by default, and make it hard to do the wrong thing around all the bundle elements.
And then the roof of the house, or the frosting on the cake, depending on which analogy you want to use, is the SAT, SBT trials and early mobility. Because if you don't have a patient whose pain's well controlled, who's awake and cooperative, and not delirious, it becomes very hard to execute weaning trials or mobility efforts. And it also gets in the way of family engagement, and disempowers the family from helping us to do our jobs.
Dr. Lin: I love it. Thank you so much for that. Before we wrap this up, because unfortunately, episode eventually does need to end.
What are the other things that you really want our audience to take away from this conversation about the A, B, C, D, E, F bundle?
Dr. Barr: The A through F bundle is a means to a higher ends. And we need to use that goal of getting patients back to the lives they left before they became critically ill and injured, our North Star. That needs to be the reason that we come to work every day, and to take care of patients.
Dr. Lin: I love that. Thank you so much. And that is so inspiring to me.
I just feel like this conversation has been so energizing and exciting. You touched on a bunch of difficulties, but that's why we're here. We're going to work on that.
And I think you've provided some really practical starter tips for people. So this has been great. This is going to conclude another episode of the Society of Critical Care Medicines podcast.
I'm Dr. Ludwig Lin. Thank you so much for listening.
Announcer: Ludwig H. Lin, MD, is an intensivist and anesthesiologist at Sutter Hospitals in the Bay Area of 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. The SCCM podcast is the copyrighted material of the Society of Critical Care Medicine, and all rights are reserved.
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