All right, here we go. So as I said, I'm going to talk about how to leverage the EHR to assist with evidence-based practices, putting them in place, as well as process improvement. So how many people here are familiar with the ICU Liberation Bundle? Okay, so almost everyone. And so just to recap, so we're all on the same page, the ICU Liberation Bundle is evidence-based practices that aim to liberate our patients from the harmful effects of pain, sedation, immobility, delirium, and lack of sleep. So they are based on the evidence-based guidelines of the PADIS that were published a few years ago now. We're about ready for an update. And as you can see picked in this infograph, each of the letters stands for a different evidence-based practice that should be provided to each of our ICU patients, whether they're on mechanical ventilation or not. A is assess and manage pain. B is provide a spontaneous awakening trial or a spontaneous breathing trial for someone who is on continuous sedation and or on mechanical ventilation. C is choose the right sedation, keep our patients awake so they can participate and effectively allow them to be up and mobile. D is delirium, assessing and then preventing it. E is early mobility and exercise because we know that that's a very important thing to prevent debilitation. It gets them off the ventilator sooner and prevents delirium as well or decreases the length of delirium. And then F is engaging the family. So why do we do the ICU liberation bundle? We have done, I've been in critical care now for over 40 years and many more people survive. So we have survivors and we always equated a success in caring for an ICU patient as saving their life and allowing them to live. But what we have found is that we've added often an undue burden by how we've managed the patients in the ICU. Yes, we saved their life, but they are left with cognitive dysfunction as well as functional dysfunction and anxiety, PTSD. And that's called post-intensive care syndrome, PICS. So we know that by providing the evidence-based ATHREF ICU liberation bundle that we can prevent them from getting PICS and we can restore them to and send them away not only alive but with optimal function both cognitively and physically. In the infographic on your right, you can see there was a collaborative done by the SCCM in collaboration with the Gordon and Betty Moore Foundation that demonstrated by providing these evidence-based practices reliably to our patients, we can decrease their time on the ventilator, decrease next day comas, ICU readmissions. It impacted mortality. And we also know that doing the more components of the bundle you do, the better the outcomes for our patients. So this collaborative occurred in 2015 to 2017, 69 ICUs in the U.S., adult ICUs and also pediatric ICUs were involved, over 15,000 patients. And the participants applied the evidence from all of the studies that supported each of the elements of the bundle and implemented this in their institutions. Along with implementing it, they collected a lot of data. And that data was very helpful. That's how we could show you all those results. But what the ask of those facilities that were participating in the collaboration is, so what do we collect now? How do we continue to show improvement, sustainment, continued improvement? How do we continue to see progression and uptick and hardwiring of these best practices? And so, Matt and a large number of other people as part of the ICU Liberation Committee here at SCCM tried to answer that question. And we answered it in two ways. One was to create a minimum data set of if you are going to evaluate how well you're performing the bundle consistently on each of your patients, what data should you collect to be able to answer that? And then the second was, one of the things we heard throughout the collaborative was, it's very hard to pull data, but it's also hard to know if the patients are getting each of the interventions because the EHR necessarily didn't support the documentation of those evidence-based interventions. And so as a committee, the ICU Liberation Committee partnered then with the two largest EMR vendors, EPIC and Cerner, to help standardize that documentation so that it would be in a line with the evidence and in line with the minimum data set. So data then could be pulled easily into re-reports so that teams could then see their performance, see where the gaps were still, and so they could continually improve. So here's the minimum data set. This was worked on in 2017, 16 and 17. And it takes each of the bundle elements and it defines what is meant by compliance. So for A example, the compliance is, because A is about assessing and managing pain, the adequate compliance would be that I have six pain assessments in a 24-hour period. So I'm doing it at an appropriate frequency. An additional data point, not necessarily meant for measuring compliance, but good information is on these pain scales, what percent of my patients had significant pain? So that you could identify whether or not you were managing pain appropriately. For B, it's both the SAT and the SBT, and it was, is this person appropriate to get an SAT? So did they pass the safety screen if they were on continuous sedation? And then if they pass the safety screen, did we perform an SAT? Whether or not they failed it or not. And so compliance is, I did a safety screen and I performed an SAT. And it's the same for the SBT. I did a safety screen, does this person meet the criteria to do an SBT? And then did I perform an SBT? And for C is, have I documented RAS? Have I documented a target level for RAS? And we know to keep our patients awake, we want them to be a RAS of minus 1 to plus 1. And did I perform those RAS assessments or those assessments of sedation or arousal at least six times in a 24-hour period? D is, have I assessed for delirium? If you don't assess for it, you're not going to know your patient has it and you can't intervene. And so that is expected to be done at a minimum every 12 hours. And so that's compliance, is that it's done every 12 hours. For mobility, it's have I performed a safety screen and then did I mobilize my patient at a minimum dangling up to walking? And then F, any of these items that the family participated in rounds, they participated in any of the elements of the bundle, were all considered compliant. So that was created. And then we wanted to create a tool once those data definitions were there, a tool that teams could then hand collect or pull data from the EMR and put it in this, so it's just an Excel spreadsheet. This is available to any member if you go on to the ICU Liberation website. There's a minimum ICU Liberation toolkit that has this Excel spreadsheet. As soon as you put the data in, it pops out your compliance graphs. And so this is what we showed when we worked with both the Cerner and Epic, showed them that this is what we would like. Here's the minimum data set. This is the information that needs to be documented to support pulling and to be able to define compliance. So you can see here, and you'll see in a few minutes that one of the EHR Cerner was able to put this in place and the graphs look exactly like what we had asked them to do. So do I have good overall bundle compliance? We know it's hard to get good bundle compliance and do all elements of the bundle. But then how did I do on each specific element? And this graph is just by month. There were additional data elements that we felt were important. They weren't there to measure compliance, but to provide additional information for improvement, so process metrics. We talked a little bit about that significant pain, what percent of your patients. Also the patients that had a documented sedation target, and what number of assessments were outside that target. So that it could give you ideas of where you need to focus your improvement efforts, as well as exercise and family. So working with Epic, so the ICU Liberation Committee worked with Epic, and they put into their foundation system a set of items that support documentation and being able to collect data specifically on ICU Liberation A-F bundle. So a storyboard, and I'm going to show you pictures of each of these, a storyboard that allows you to know what the target arousal level is for that patient. If there isn't a target arousal level, a BPA that will remind you you need to put one in. And then tasks for different clinicians, as well as the ability to get a snapshot of your unit of all the patients and where they are relative to completion of each of the elements of the bundle. So here's an example of the target RAS. You can see this is on the storyboard on the side if you're an Epic user. And so the target arousal level here is RAS of minus 1 to minus 2. It will look red if there isn't an arousal level. And this is the BPA that I will get if I don't have an arousal level in. This is an example of what the flow sheet looks like. And there's a single ICU liberation flow sheet, but you don't have to record everything in this flow sheet if you don't want to. If you're recording it somewhere else in your workflow, it will automatically populate to this worksheet. So it allows it to fit nicely into both nursing and RT's workflow. And so you can see each of the letters of the bundle are included. You have row information on the side that will tell you what compliance is and define what that metric is or what you should be achieving. Physicians in rounding, you know, this is one of the things I hate about most of the EHRs is that depending on what discipline you're in, you see a different view of the chart, which is very frustrating. As a nurse, I see something different than the physicians. And so Epic and Cerner, please change that because we all should be seeing the same thing. Anyway, so a physician view, they're able to, so someone could bring up on rounds a summary of how I'm doing on the bundle. So it will be easy to talk about it on rounds. At University of Michigan, on our summary report where you can see all the vitals, the intake and output drips, we put an according report on the bottom that summarizes the A through F bundle. So here you can see it in context with other vital signs and other key information in the chart. And here's that compliance summary that I talked to you about that you can get a snapshot of each of the patients on your unit and how they're doing with each element of the bundle, which is great. So real-time feedback, as the charge nurse or as the medical director or the attending on service, I can take a quick snapshot and know where everyone is and where I need to maybe put my energies. Cerner did very similar things. They did a workflow component and at-a-glance as well. You can see here, this is their documentation system. The top portion here is that at-a-glance, each of the patients and how are they doing. And then the documentation system is on the bottom. Cerner has also been able to put in those compliance reports so that you can, and you'll see these look very similar to the graphs that were used in the ICU Liberation Collaborative, as well as the compliance graph that are part of the minimum data set. So they have created the compliance dashboard where it's overall bundle compliance and then each of the different elements. And then also they picked up those other process metrics, delirium present, what was the highest level of mobility, as well as number of times percent were out of target of our target RAS. So it's important to be able to use these. You have all this information. If I'm going to improve, I need to have that data be fed back to me as a clinician, either individually on my patient by looking at that dashboard of how am I doing individually, as well as in an aggregate. So as a committee, a local committee, I can look to see how we're doing and then work to improve. So I can trend. If I'm trending up, that's good. If I have a downward trend, you know, maybe I need, it's not, it's a minimum data set. So it's going to tell you compliance, but it's not going to tell you necessarily why you're not meeting it. So you might need to collect additional data and take a deeper dive. And the, often in a downward trend or you're not seeing the compliance level that you want, it's, it can be education, it can be, you know, with the SAT, common people feel that the patient's going to harm themselves. They're going to get wild and pull out all their lines and tubes. That's why I don't want to turn it all the way off. I'm just going to eke it down. And so a lot of it is fear because one time, two years ago when I did that, someone got wild and pulled out all their tubes and six people needed to be pulled into the room to hold them down. So this data will assist you then in trying to target solutions to where you see the barriers. There was a recent study that was published where they looked at how you can, how leveraging the EHR, both with documentation and regular data, resulted in significant improvement in compliance with the bundle. And so in this study, it was a stepwise approach. It was a single center study, but in eight ICUs, four ICUs were the intervention group, four were the control. In the first month, they did education on each of the bundle elements to all of the disciplines. In month two through four, they educated them on the data and fed that data back weekly to them. With the education, they saw an improvement of compliance. Their initial compliance was only 9%. Overall compliance, you think that that's low, but in that ICU collaboration program that was done in 2015 to 2017, the average compliance at the end was only about 20%. So it's hard to do all of them, all of those elements. And so after education, they saw compliance improve from 9% to 16% and did not see that same change in the non-intervention units. And then months two through four was feeding back that data, and they saw the compliance improve even more and be sustained from 16% to 21%. So statistically significant. And one of the things, they were doing this study during COVID, and they had started it before COVID, and they did not see a degradation in compliance in those units that were getting those weekly reports. They stayed sustained. They didn't gain a whole lot during the COVID period, but they didn't lose when the other comparable units did. So this is a very important study. This is the first time this has been studied, and it shows us that integrating the bundle into the EHR and supplying data and feedback to the users can improve performance. And they also showed improvement in the same things that all of the literature has shown, improvement in mortality, time on the ventilator, and the percent of patients getting discharged to home versus needing to go to a skilled nursing facility. So very important. So in summary, it's important to make it easy to do those evidence-based practices, and in this example, ICU liberation A through F bundle, it integrated in the EHR, assists you in doing that. Coupling that with performance reports, you can then achieve better compliance and better outcomes for our patients. And that's my story. Thank you.

Electronic Health Record

EHR

ICU Liberation Bundle

evidence-based practices

post-intensive care syndrome

documentation