Consistent ‘Bundled’ Approach Optimizes ICU Liberation

Author: Thomas Rosenthal

Anesthesiology News

Consistent application of an evidence-based bundled approach (Table) reduced the number of days critically ill patients were mechanically ventilated, lowered the incidence of ventilator-acquired pneumonia (VAP), and cut patients’ length of stay (LOS) in both the ICU and the hospital.

That was the conclusion of a study that used the Society of Critical Care Medicine’s (SCCM’s) “ICU Liberation ABCDEF Bundle,” which has been found to improve outcomes for patients in the ICU.

Building on the ICU Liberation approach, the ICU staff, surgery residents and faculty at the trauma center at Community Regional Medical Center (CRMC) in Fresno, Calif., created a multidisciplinary Sedation Mobilization Assessment Rounding Team (SMART) to carry out the daily rounds in the trauma/surgical ICU. The goal of the SMART group was to improve trauma patient outcomes through consistent implementation of the ABCDEF bundle, while also evaluating the ICU team’s sedation practices and improving patients’ delirium assessment through consistent use of the Confusion Assessment Method for the ICU.

CRMC had been one of 68 U.S. hospitals that participated in the ICU Liberation ABCDEF Bundle Collaborative study (Crit Care Med 2019;47[1]:3-14), which found that the bundle provided significant improvements in clinical outcomes. The present study, as explained by lead author Wade Veneman, RRT, CRMC’s clinical educator, respiratory care services, was to further improve on ICU outcomes by more consistently implementing the ABCDEF bundle. The study was presented at the SCCM’s 2019 Critical Care Congress (abstract 63).

3 Cohorts Studied

In the study, the SMART group used a tool incorporating all the elements of the ABCDEF bundle—as well as care bundles for VAP, central line–associated bloodstream infection and catheter-assisted urinary tract infections—to track progress toward the daily goals established for each patient. The pain, agitation and delirium order set also was updated for each patient.

• six months before implementation of the ICU Liberation Collaborative (baseline);
• 17 months during implementation of the ABCDEF bundle practices; and
• 12 months after the collaborative in which CRMC’s SMART group conducted its expanded bundle practices.

The SMART approach also led to a decrease in the duration of mechanical ventilation, which decreased by 11% (5.2 vs. 4.7 days; P=0.11) from the baseline period and decreased ICU LOS from 9.2 to 6.4 days (P=0.005).

The researchers found other benefits, too, such as a decrease in the need for continuous benzodiazepine infusions (by 50%) and an increase in performance of spontaneous awakening trials (by 32%).

“Before we began the collaborative, the majority of our patients received continuous benzodiazepines,” Veneman said. “The rates of benzodiazepine use were similar in the During group but dropped significantly after the formal collaborative period ended.”

Before the collaborative was implemented, delirium was evaluated in fewer than 10% of patients, Veneman said. “After extensive education, delirium assessment improved to 73% and was found to be present in 45% of the patients,” he said.

Veneman added that the SMART approach enabled them to sustain the ICU Liberation bundle at their facility.

Reduction of ICU LOS ‘Phenomenal’

“This study is an excellent complement to the national collaborative of ABCDEF bundle,” said E. Wesley Ely, MD, MPH, FCCM, a professor of medicine at Vanderbilt University School of Medicine, in Nashville, Tenn., who had announced the results of the 17-month ICU Liberation ABCDEF Bundle Collaborative study at SCCM’s 2017 Critical Care Congress in Hawaii.

Calling the results of the CRMC’s 12-month study “reassuring and consistent with earlier studies, and yet extending to a very important new population,” Dr. Ely said the hospital’s SMART approach put the ICU Liberation Bundle Collaborative in play in exactly the way it was designed to be used. He called the three-day reduction in ICU LOS from 9.2 to 6.4 days “phenomenal in lowering the risk of delirium and other problems associated with ICU mechanical ventilation.”

The ICU Liberation study of 15,226 adult patients in 68 ICUs found that the ABCDEF bundle “showed significant and clinically meaningful improvements in outcomes, including survival, mechanical ventilation use, coma, delirium, restraint-free care, ICU readmissions and post-ICU discharge disposition,” according to the results of the 17-month study presented at SCCM (Crit Care Med 2019;47[1]:3-14).

The study sought to evaluate the bundle performance compared with the historical practice of caring for ICU patients by keeping them heavily sedated, immobilized and isolated, according to the researchers.

The ABCDEF bundle is applied to all patients in the ICU every day, regardless whether they are mechanically ventilated or their diagnosis. “It focuses on symptom assessment, prevention, and management rather than disease processes,” the researchers noted.

“The team-based ABCDEF bundle approach is also unique in that its ultimate goal is to produce patients who are more awake, cognitively engaged, and physically active, which ultimately serves to facilitate patient autonomy and the ability to express unmet physical, emotional, and spiritual needs,” they added.