Good afternoon, good morning, good evening, depending on what time of day you're listening to this presentation. My name is Michelle Vallis, and I'm going to talk to you about some strategies that we can use to liberate patients from mechanical ventilation. Specifically, we're going to focus on using the ABCDF bundle. So as I said, my name is Michelle Vallis. I'm an associate professor at The Ohio State University College of Nursing, and my primary interest and research focus and clinical focus is on ways we can prevent ICU-acquired delirium and other symptoms that patients experience during their ICU stay. In terms of disclosures, here's my current research support. We have a current active R01, which we'll be talking about a little bit today that focuses on the ABCDF bundle and some of my other past related support. So before I begin the presentation, I just want to say how disheartening it is that we can't be together. I was so looking forward to going to Chicago Proper for the first time, and I normally try to be super engaged with the audience and focus a lot of my presentation time on answering the real-world questions that come up when you try to implement this rather complex bundle into everyday care. So hopefully, we will all be together in Puerto Rico for the next SCCM conference. That would be fantastic. But in terms of our objectives today, what we're going to really focus on, again, is the ABCDF bundle. We're going to be talking about the evidence that was used to build the bundle, why the bundle is so important in terms of what we're learning over the last few years about post-intensive care syndrome and post-intensive care syndrome family. And then also look at some of the strategies that we can use to either help facilitate the bundle or at least overcome some of the known barriers that you will experience when you leave this great course and are all engaged and want to try to get this into your ICUs, some of the barriers that you might face when you're doing that. So what do we know? Well, as I said, increasing evidence is telling us that we're getting really great at improving ICU survival rates. So we've made a lot of progress in terms of reducing ICU-acquired mortality or the number of patients that are dying in our care in the ICUs. Unfortunately, we also know that millions of the people that do survive critical illness experience these profound and often persistent, we'll see, impairments in their physical health, mental health, and cognitive health. So this collective impairment that our patients are experiencing after being in the ICU has a new term, and it's called post-intensive care syndrome. It's kind of not even new over, as you can see at the bottom of the slide there, proposed quite a few years ago. But what we know is that PICS is often acquired in the ICU, and it's commonly exacerbated by certain factors. So for example, if a patient requires mechanical ventilation, if a patient experiences certain symptoms, or if they remain immobile and not mobilized while they're in the intensive care unit, they are deemed precipitating risk factors for the acquirement of post-intensive care syndrome. And most importantly, they're being demonstrated over and over again to be somewhat modifiable. We know that it is, as I said, a complex relationship, but in terms of the symptoms, if you think about all of the symptoms that our patients experience while they're under our care, right? So we know pain, ubiquitous. Almost every patient, whether they're on or off the vent, whether they had surgery or not, is going to experience pain sometime during their ICU stay. One symptom that's often neglected, or at least not measured, but spoken to a lot is anxiety. Many of the treatments, particularly mechanical ventilation, can induce extreme anxiety. We imagine, and I'm sure we teach our students this, but imagine breathing through a straw or being awake during mechanical ventilation, often anxiety-producing, being away from family members, another reason, or not being able to communicate their needs effectively because they're non-vocal now because of the ET tube, right? So pain, anxiety, and delirium, that acute change in mental status, weakness, very common symptoms that we see, and we know those symptoms have a role in some of the outcomes that not only us as clinicians, but our patients care about most, right? Patients with those symptoms are more likely to stay on the ventilator longer, develop PTSD or post-traumatic stress symptoms. Depression, obviously functional decline, you're lying in bed and you're losing all this muscle mass, and we'll see that in another lecture that I'm providing about the need for early mobilization in the acutely and critically ill, but particularly in the older adult population, when collectively experienced, increase someone's risk for new institutionalization. Well, why do we care? I don't know if you've ever had a relative that's been in a nursing home lately, but oftentimes experiencing such extreme functional cognitive decline and where you need to get newly institutionalized or go to a nursing home or a prolonged stay, a lot of patients consider that a fate worse than death, right? Or developing new onset dementia, a fate worse than death. So collectively, as we can see, these symptoms are truly problematic. In particular, decades of research now, the number of delirium-related articles has just grown exponentially in the last few years, particularly since the 90s when we, and early 2000s in the ICU, when we actually had a way to measure delirium. Now, if you've been a intensive care unit practitioner for longer than a day, you know that patients, while they're in the ICU, frequently experience these profound changes in mental status, right? Years ago, and I'm guilty of this myself, we would talk about, okay, there's something wrong with him. I don't know exactly what it is. He is not right. We used to call it the not right syndrome. But now we have a term for some of those mental status changes that we're seeing in the intensive care unit. And as I said, over the years, the research in this field has just grown exponentially. One of the things that consistently comes up in the literature is the relationship between delirium, not only in the ICU, but delirium in the acute care setting, and the relationship between mortality. So if you're interested in this topic, here's a great paper that you can refer to. But this was a meta-analysis of 71 studies where they looked at patients who were older than 65 years of age. They were in some type of hospital inpatient setting, and the studies had measured delirium with a valid and reliable instrument, and they looked at the quantitative effects on delirium and most importantly, obviously, mortality. And what this meta-analysis showed that was older adults with delirium actually had significantly greater odds of mortality compared to non-delirious controls. And what's interesting is that patients with delirium in the different settings in the hospital also had different odds for delirium, right? So I mean, higher odds for mortality. So patients in the intensive care unit, odds ratio with this meta-analysis was like 7 highest rates of mortality in the ICU population. But we saw in medical floors, surgical floors, mixed units, mixed medical surgical units, and even in the post-intensive, post-acute care setting. So strong and pretty consistent relationship with this association between the development of delirium and mortality. And fortunately, despite the advances that we have made in delirium research, the bundle being a very important part of it, that delirium associated in hospital odds of mortality really hasn't changed much in 30 years. So that's a little bit unfortunate, but we are, again, starting to make some progress. As I said before, in addition to the traditional outcome measures, cognitive impairment and the association between delirium and long-term cognitive impairment. Debate in the literature of it's kind of a chicken or an egg thing, right? Which came first? Did the patients come to our ICU with already pre-existing cognitive impairment? And what the severe illness just unmasked cognitive impairment before? It's kind of a little bit of an outdated thinking because there's been several studies that have been done. And here, if you're interested in the relationship between delirium and cognitive decline, this meta-analysis here, great to refer to. But it was interesting because they looked at some of the core features of delirium and the relationship it had with mortality. So when patients experience delirium, we often see disturbances in memory or orientation, particularly attention. Sometimes they'll have visual or auditory hallucinations and things like that. But when they looked at the relationship between cognitive impairment, when collectively in this meta-analysis, they did find this rather strong relationship, again, with delirium and new onset cognitive decline. In terms of critical illness, this is a classic study, if you haven't seen it, I highly recommend it. This was done by a group of intensivists in Vanderbilt who specialize in critical illness, particularly in delirium. But this article looked at the effect of delirium in the intensive care unit on long-term cognitive impairment. And as you can see illustrated in this slide, it's pretty dramatic findings is what they found. So looking at this slide, we can see what a normal global cognitive score would be. And then we can see that orange line that you'll be seeing on the screen right now is mild cognitive impairment. And the TBI would be cognitive impairment that is comparable to traumatic brain injury and that red one, cognitive impairment that's comparable to someone who has Alzheimer's disease. So what we can see is in both young and old, but particularly in the old, patients who survive a critical illness are having pretty substantial changes in their cognitive ability. And you can see this is long-term over 3 to 12 months. So something is happening in the intensive care units, presumably that's affecting their ability to function after critical illness. Finally, the last thing I'm just going to say briefly again, because the lecture is not really focused on delirium, but to understand why we need to intervene, these are kind of some of the key points that you might bring up to your C-suite when you go begging for money to make these substantial changes that we should consider making in our intensive care units to make them a little bit more patient-centered. The economic cost of delirium is just huge. Again, another, if you're interested in the topic or to bring for the C-suite about why we're going to be investing in this effort, at a national level, inpatient delirium, it's estimated it's costing us somewhere between $6.6 billion and $82 billion a year alone in the United States. That's a lot of money, right? And that's, if you see the bottom of the screen there, that's assuming a pretty low prevalence of delirium. So very, very costly disorder. As I said, in addition to that delirium research growing, the new Society of Critical Care Medicines, the most recently released, building off great work in the past, their pain, agitation, delirium, immobility, and sleep guidelines, robust evidence that we can improve clinical outcomes, we can help improve our patients' outcomes, both short and long-term, when we take integrated approaches to managing our patients, right? Particularly if we take integrated, interprofessional approaches to mechanical ventilation liberation, symptom management, and immobility. So over the years, that PAD, the pain, agitation, and delirium focus, has now incorporated those other really important experiences our patients have in the intensive care unit, that immobility, right? Tons and tons of strong evidence there about the negative effects of keeping our patients immobile, deeply sedated in bed, and also sleep, right? Classic. Should be on everybody's desk. In terms of bundles, if you're not familiar with the bundle, if you're new to quality improvement efforts, they really started probably back in the early 2000s through the Institute of Healthcare Improvement. They're probably best known for their work with the bundles. A bundle is a small, straightforward set of evidence-based practices that when performed collectively, right, so you have these evidence-based practices, you're putting them together collectively and reliably, meaning the patient's getting those evidence-based interventions reliably, that they've been shown to improve patient outcomes. So bundles are now ubiquitous in healthcare, and again, that could be another lecture about what makes a bundle a bundle, but we've had great success, particularly in critical care. We're like the champions in terms of bundle when you think of what we've done with severe sepsis, the ventilator-associated pneumonia bundles, central line stream infection bundles. So a lot of different types of bundles have had great success. So in terms of addressing the need to get our patients off the ventilator early, liberating them from the ventilator and liberating them from the harms of deep sedation, the ABCDF bundle. Now what you're seeing on this screen right now is the current version of the ABCDF bundle. It has evolved over time as the evidence has evolved over time. These are the components, and we'll look at the specific components and how they're operationalized in a couple screens down, but this is the current A through F components of the bundle. What's neat about this bundle? I just think it's the be-all end-all of everything, but what's unique about the ABCDF bundle in comparison to the other bundles that have had great success like the sepsis bundle or the ventilator-associated pneumonia bundle or the catheter-associated urinary tract or line stream bundles? Well, the ABCDF bundle is not disease specific. You apply this bundle to patients with almost every different diagnostic category, right? So it's not specific to a disease. It's also team-focused, so every member of the interprofessional team, ICU team, has a role in the bundle, a very important role in the bundle. It's patient and family-centered because ultimately what we want to improve is those patient and family outcomes. And it's also flexible. It does allow you to adapt the bundle to meet the needs of the patients that are in your intensive care unit or your particular population. So as you can see illustrated again on this slide, this is one of the earliest, the original ABCDE bundle that took the components of spontaneous awakening trials, spontaneous breathing trials, coordinating them, delirium and early mobility, and how they impact the symptoms, who's involved in the particular, you know, A through E part of it, so that your nurses, your physicians, your pharmacists, your respiratory therapists, your PTOT specialists, patients and families, and how they all kind of interact. So in terms of looking at the evolution of the evidence behind the bundle over time, one of the original studies was done in, actually University of Nebraska, but it was an 18 month study and it was the first one that took, again remember, to be a bundle you have to have evidence supporting the interventions. You can't just pick something and because it comes, you know, in the A through F order or because it sounds intuitively appealing to do it, that for a bundle to work there has to be, there has to be evidence behind the bundle. So this was the first study that took the individual components, so the spontaneous, the evidence supporting spontaneous awakening trials, spontaneous breathing trials, the importance of coordinating the ABCs, so, you know, that ABC trial data, delirium and early mobility, and this was the first one to kind of put those together to see, hmm, we know the A, B and the C work, we know the D works, and we know the E work, what happens if we put it together? Is it going to be really a bundle? Will you get better effects than if you just did those interventions alone? So again, 18-month included five adult intensive care units, a couple patients were on the ventilator from step-down units, 63% of the patients in this study were on mechanical ventilations, mechanical ventilation, 40% were surgical, and this initial first trial of the bundle found that patients, once the, it was a pre-post study, so what the researchers looked at is what happened once it was implemented into care. So we made this bundle, we rolled it out as institutional policy, we defined everybody's roles, and then say on this day, everybody going forward is going to get this bundle. And what happened once that was rolled out is, in fact, SATs became more frequent. So more patients had an SAT at least once during their ICU stay. More patients, as you can see here too, also had a spontaneous breathing trial during their ICU stay. More patients were mobilized at least once during their ICU stay. And in terms of patient outcomes, so we showed that we increased the actual performance of these interventions, and then what happened to the patients? Well, we found that patients in the post-period actually were on the vent three fewer days. That's a good thing, right? Want to get the patients off the ventilators earlier. We actually found that the incidence of delirium was half. That's pretty remarkable. So again, pre-bundle, 40% of the patients had delirium, post-bundle, 20%. That's a remarkable improvement in the number of patients that experienced delirium during their ICU stay. Again, patients that, once the bundle went up as standard of care, were more likely to get out of bed at least once, so that's good, and very, very important. There was no adverse events associated. There's no change in the number of people pulling out their tubes, or accidental device removals, no change in the number of patients that had to have a CAT scan for mental status changes or restraints. So patients were more likely to get the interventions, had better improvement in outcomes, and importantly, no increase in adverse events, because that's everybody's biggest fear. It's a logical fear, right? It's scary to get people up and walking. The next study went from a single center to a multi-center study. It had, so from single center to multi-center involved seven community hospitals, important because a lot of our care is, in the United States, is actually still delivered in community hospitals, right? And we always do this great research in academic medical centers. This is one of the key takeaways from this particular study. So seven community hospitals out in the center healthcare system. They also, a unique aspect to this study was they focused on interprofessional team training. So yes, they taught the clinicians about the importance of the bundle, how to do the bundle components, things like that, but they also focused on improving the interprofessional team communication. Study included over 6,000 patients. A quarter of them, hopefully they were all ventilated, a quarter of them required mechanical ventilation, and again, mixed general surgical patients. So what did we find with this study? Barnes and colleagues, so another takeaway when you're going back and teaching this to your staff is another unique aspect of this study is they looked at patient outcomes traditionally, right? Whether they got the bundle or not. And what they found was both survival and delirium coma-free days, right? Look at the changes, the mortality improvement, pretty incredible. Delirium coma-free days, and again, these models, these improvements that we're seeing in mortality and delirium coma-free days are adjusted for severity of illness, age, mechanical ventilation, status, and things like that. So again, consistent. Study one found an improvement, study two found an improvement, but look at this. This was unique in that they looked not only on whether or not you got the bundle, but they looked at what happened as you increase the percent of bundle, right? And it was the first to show that for every 10% increase in the proportions of days that a patient got the total bundle, that the patient experienced 7% higher odds of survival, 2% increase in delirium coma-free days, but, right? So you get the bundle, you're going to have these great improvements, but also there were similar dose responses with partial bundle compliance. So even if you weren't perfect, and even if the patient didn't get every evidence-based intervention every day, what they demonstrated is the more they got of those bundle, those evidence-based interventions, the better the outcomes were. So this dose response, isn't that fantastic? Super exciting. The next study that we'll talk about was the Society of Critical Care Medicine's ICU Liberation Collaborative, and I guess many of you were involved in the collaborative. It was supported through funds from the Gordon and Betty Moore Foundation, and also, of course, the Society of Critical Care Medicine, who had already demonstrated a ton of success, again, with these other campaigns, right? Sepsis, ICU liberation. The collaborative itself ran from 2015 to 2017. We had 68 ICUs, and we also included 10 pediatric intensive care units who really did some amazing, groundbreaking, transformative work, if there's any PEDS people in there, so transformative work in such a short period of time, the PEDS group also did. But these ICUs, again, variety, medical, surgical, cardiac, we even had, I think, one or two neuro ICUs in there. The overall goal was to facilitate adoption of the Society of Critical Care Medicine's pain, agitation, delirium, immobility, and sleep guidelines through the ABCDF bundle, right? And now, kind of known as the ICU liberation bundle. So focused on getting all of those hundreds, if not thousands, of studies that were in the PADDES guidelines. If anybody doesn't think these interventions are evidence-based, please pick up the PADDES guidelines. You'll see the hundreds of studies supporting what we're telling you to do. Really unique geographic distribution of these hospitals, so we even have a site, it's Puerto Rico on here, yep. So nice representation, north, south, east, west, number of hospitals. The first paper that came out to it, came out from this collaborative, was Dr. Brenda Pun led the study, and it was published here, if you're interested, you can get it, Caring for Critically Ill Patients. And we call this kind of the outcome paper. So what this paper did was say, what happens to the patients if they got the bundle? Because that's what, everybody cares. Does it work? There is now a randomized control trial that ever looked at ABCDF bundle. Can't do it, but good luck if you want to try. Anyway, so this first bundle, this first paper that we'll be talking about tells you what happens with the patients. But most importantly, okay, so these, if you're taking notes, take some notes here. Most importantly, we had to, in the ICU Liberation Collaborative, operationalize the ABCDF bundle. Now this is the kind of first test with the new bundle, and we're going to see. The previous versions, again, were focused on the awakening, breathing, coordination, delirium, and immobility. This has changed. Why did it change? Why did the bundle evolve? Again, the great thing about the bundle, that it is able to evolve as the evidence comes out. Well, it coincided, again, with all the great work that Patty's guidelines that demonstrated the effects of, devastating effects of pain, the need for more effective pain, agitation, delirium assessments, the role of immobility. And it also coincided, if you remember from our introductory slides, with the increasing recognition of the devastating effects that PICS and PICSF have, right? So family. So the new bundle has all the old components, but some really great new ones. And here we're going to talk about what the A and the B stand for, because I know you're all dying to know what they are. So A is now assess, prevent, and manage pain, right? Again, important that that syndrome is that we treat and manage patient's pain, and that we're monitoring for pain reliably. So the A, assess, prevent, and manage pain. Operationally, in the ICU Liberation Collaborative, because you're going to get a question, well, how often should we do it? Well, after very long discussions, operationally in the collaborative, we define at least six times a day. You're going to assess for pain, and you have to assess for pain using a valid and reliable instrument. And that's tough, because let me tell you how many different pain scales there are. And some people even use kids' pain scales in the adult population, and no, no, no. So you have to assess pain using a valid and reliable tool. And in this collaborative, we recommended that it was monitored at least six times a day. Okay? So those tools, you can see them there. You're either going to assess with that numeric rating scale, the critical care pain observation tool, behavioral pain scale. And in the collaborative, we did a lot of education regarding taking an analogous sedation approach, meaning treating patient's pain first before sedating them. So operationally, that's your A. Oops, sorry. Every day that they're in the ICU. Those awakening trials and breathing trials should be guided by a safety screen. We didn't tell the individual sites what had to be in the safety screen, but there's great safety screen questions out there for you to use. We didn't tell them what success-failure criteria are either. So each individual site was able to modify, locally adapt to contextual needs. How the SAT and SPT were delivered in terms of which patients could get it, and how do you determine if it was success-failure. To be eligible for a SAT, you needed to be on continuously infused sedation, either analgesics or sedative medications, benzos, propofol, dex, continuously infused, or getting intermittently scheduled sedatives. So the patient was getting sedatives every two hours around the clock, something like that. And for an SAT occur, we defined it as that sedation had to be shut off. So you had to shut off the sedation. Same thing again with the spontaneous breathing trials, locally adapted, the safety screens, but in the collaborative, patient had their ventilator shut off once a day. So if the patient was on a trach collar, if they had a trach, they could do a trach collar. They could drop their pressure support if they're on the vent to zero. But once a day, the patient should be getting both if they meet those criteria. C in the new bundle is choice of analgesia and sedation. Specifically, we are looking at, in terms of the ICU Liberation Collaborative, C was defined as not so much what meds they were getting, but how we were monitoring their sedation level. Hugely important, right? You know, all of those studies out there that are showing you the relationship between deep sedation and pick an outcome, and if the patient's deeply sedated, poorer outcomes. Pick an outcome, and I'll find you a study that will show that deep sedation, really we got to avoid that deep sedation. In the collaborative, we again had to say, because kind of tough, hospitals take different approaches to how frequently these sedation assessments should occur. So in the collaborative, we defined it, or we suggested that they occur every, that sedation assessments occur six times a day. And again, has to be with a valid and reliable tool. Patty's guideline recommended tools are the RAS and the SAS, you can see them up there. We did a lot of teaching regarding the need to target light levels of sedation, light as possible, for the benefit of the patient. D, delirium, assess, prevent, and manage in the new bundle. Delirium assessments, we recommended occur at least two times a day during the collaborative. And not surprisingly, that these delirium assessments are done with either the CAM ICU or the intensive care delirium screening checklist, both shown valid and reliable in the ICU population. So you had to use a valid and reliable tool. A lot of teaching around non-pharmacologic interventions, I always say part of that non-pharm is the avoidance of the pharm. Those meds that we know are delirogenic, so a lot of teaching around pharm and non-pharm are put into delirium management. E in the new bundle is defined in the ICU liberation collaborative is mobility activities. So E, early mobility and exercise. We defined it as a mobility activity that was greater than a passive range of motion, right? So if a patient dangled at the edge of the bed, stood, walked, marched, walked up and down your hall, that was considered early mobility, so not range of motion. Passive and active range of motion didn't count. That was not a mobile day. They had to do one of these things to be mobilized. Finally, F was added to the bundle, again, because of the importance of engaging family members in the care and planning of care for critically ill patients. So for the F part of the bundle in the ICU Liberation Collaborative, we considered the F delivered if it was documented somewhere that a family member was educated on the bundle and or they participated on daily rounds in a team, family, conference, plan of care, or helped participate in one of the ABCDF bundle related care. So that is the most current operationalized definitions of the ABCDF bundle. If we remember when we reflected back on the Barnes Daily study that showed incremental improvements, so the more you do with the bundle, the better patients were. So two important definitions, and we're going to show you what happened when patients got this bundle. Two important definitions, complete performance. That means the patient got, on any given ICU day, every single element of the bundle that they were eligible for, right? So if they're not on an event or not receiving continuously infused sedation or intermittently scheduled sedation, they wouldn't necessarily be eligible for that part. But for complete performance, they got every single evidence-based intervention that day. Proportional performance we define as the number of bundle elements that they got on any given day. So maybe they got the A, B, and the C, but they didn't get the E and the F. So the percentage of bundle elements, again, that they were eligible for, and they got that different, right? One of the major contributions, and it's so funny to watch this stuff evolve over time, of this study is that we needed, and I in particular fought for, objective measures of performance. We looked at, in this study, whether or not the patient got the intervention. To me, I don't care why the patient didn't get it. If you set your safety screen criteria for an SAT so tight that the patient's never gonna get the intervention, I don't care. I want to just know whether or not the patient got the actual evidence, right? It's different than compliance. Compliance kind of takes into account, and we didn't look at it in this study. So compliance would be the patient, you did your safety screen for your SAT, and the patient was having active seizures, so appropriately, you did not do an SAT, right? We're not gonna shut off the benzos because the patient's actively seizing or whatever. Whatever. Pick a different condition. So it's different than compliance. This, I think the beauty of this study is we looked at, we don't care why you gave it or didn't give it. We just wanted to know, did the patient get this evidence-based intervention that we know saves lives, right? Again, different. We know not everybody's gonna get the bundle, right? There's gonna be days the patient should not get any particular intervention. So this, I think, was a nice, easy way of doing it. Yes, no, they got it, right? As we defined on those previous slides. So let's look what happened when they got the bundle. These will be a quick run-through, and I can just tell you right now, every single thing got better. But when we're looking at complete performance, so the patient got every bundle element that they were eligible for that day, 17% ICU discharge, 19% more likely to be hospital discharge. Look at that reduction in death. Pretty fantastic, right? This is, again, complete. Here's some more complete. If the patient got every part of the bundle on that given day, more likely to...mechanical ventilation improved, less likely to have coma, delirium, less likely to be physically restrained. Now, you can see that significant pain there went up a bit, but not really too much and not really statistically significant. But pain was the one, I guess, that we could say that we didn't, but that's kind of expected a little bit, right? Because now, if your patients are much more awake because you've done the ABCDE part of it, then they're more likely to tell you have pain, but we'll get back to that. We also looked at ICU readmissions, less likely to be readmitted to the bundle if they got the complete bundle and had better outcomes in terms of where they went in terms of hospital discharge. So that's with the bundle. How cool is this? Look at what happened with the dose. You see in the same dose response curve that we saw in the Barnes Daily study, we're seeing it here. So if you look at the bottom, zero versus 33, so the patient got 33% of the bundle on any given day. And then if you go up 50%, 60%, 80%, 100%, you see how that beautiful incremental improvement in, again, any given outcome, you'll see in these next few slides, take them home, use them. But the more elements of the bundle they got, the less likely they were to die. More likely to have an ICU discharge, get out of the hospital earlier. Mechanical ventilation. Again, look at this. Strong demonstration of the more likely to come off mechanical ventilation with the more elements that you get of the bundle. Coma, delirium, physical restraints. See this remarkable consistency? And here's that pain again. So unfortunately, yes, there was a small increase in significant pain episodes with the more parts of the bundle. Readmissions, again, C-suite when you're talking to them. Readmission data, discharge facility data, remarkable. So now we have, and there's other really great ABCDS-related studies out there, but now really some strong and very consistent evidence showing improvements in outcomes with the bundle. The next question we ask, we have these great sites, highly motivated, fantastic, dedicated clinicians, and we spent this time with them. We asked overall, so we just in that last paper demonstrated clinical outcomes again improved with the bundle, complete is best, you get the best improvements if you give it every day as prescribed, every bundle element, but you get better with the more parts of the bundle that you get. What happened to the ICUs over time? So our question that we were looking at was, did participating in this large quality improvement project increase performance of the bundle? And in fact, it did. So we can see here, if we're looking at the complete performance of the bundle, when we started the collaborative nationally, so again, we're talking nationally, right? So we had six state centers, we're seeing less than 3% of patients were getting the bundle on a regular basis. But we tripled, these committed clinicians tripled the amount of patients that received the bundle by the end of the collaborative, and that was a short period of time, right? That 14-month implementation, really short period of time. And we can see the same thing with proportional performance. So we could pat ourselves on the back and say, hey, great, we tripled complete performance rates of the bundle. Or you could take the negative side, which I sometimes have a tendency to do, oh, yeah, we tripled performance, but now look, less than 15% of the patients got the bundle at the end of the collaborative. So again, chicken and cotton. What are the problems? Where are, why did we have such relatively low performance of the bundle? So we looked and saw, well, I think we could all guess which ones would probably be the most challenging to implement, but this slide, I think, clearly demonstrates where we need to go moving forward, right? So we see, hanging out there at the bottom, the early mobility, very low performance by the end of the collaborative, the spontaneous awakening trials and spontaneous breathing trials. So if we just look at the awakening and breathing trials and the early mobility, even by the end of the collaborative, they're all pretty much less than 40%. We are doing, we did, we made remarkable improvements in the, some of the other components. Look at that F, flap, flap, flap, woo, way up. And the A, C, and D, the pain, agitation, sedation, delirium assessments, really remarkable improvement in their frequency and documentation of those assessments. So big takeaway here, I think we still have some way to go there, right? The next thing we looked at, trying to understand exactly, you know, why is this being so challenging? We looked at individual variation. And what we found was, although, you know, overall this data could look rather disappointing, we had some great individual ICUs that performed well. So we had some high performing intensive care units. And it's neat because if you look, intensive care units might have been stellar at, say, doing the E. You see that outlier, if you look at element E all the way to the right, you know, 90% of their patients mobilized. I could tell you probably what site that was because I know they're PTOD. Some of the ICUs got none, but again, that one site over there, that outlier is 90% doing it. And it's pretty consistent, again, all of those elements. You see that there's high performers and low performers. So something seems to be happening in terms of that, again, individual culture and the individual performance of these individual bundle elements. One of the things that we learned throughout the collaborative was we did so much teaching and so much emphasis on strategies to increase ABCDF bundle adoption, right? And in the literature, there are a number of strategies, they're called implementation strategies, that you can use to increase adoption of any evidence-based practice, right? We know some of these. Look at how many there are. This is, I think, from the Eric Project, 68. Last count, I think 68 different strategies you can use to consider using to increase any evidence that you want and to practice, you know, a lot of them, champions, our poor champions, right? We have those champions doing everything. But provide audit and feedback, conduct a needs assessment, use implementation advisors, right? Tons of different ways that you can get evidence to practice. And we did really kind of take a kitchen sink approach with the ICU Liberation Collaborative and did the best in terms of what we know works and doesn't work, and then let the individual ICUs pick and choose what strategies they wanted to do with their sites. But there's all different, there's a number of different ways you can use to facilitate this, right? There's a lot of different great resources out there that you don't have to redevelop. So we have all the PowerPoint, SCCM has all the PowerPoints for all, you know, our lecture on the A, our lecture on the B, if you're more interested, that you could go and they're already developed, just tweak it maybe to your organization. And fortunately, through this experience and through prior quality improvement work in this area and other areas, there are just so many different barriers and facilitators when you go and try to implement this, right? This slide up here is showing you a implementation framework, but basically things that you need to consider are who's involved in the actual implementation. They can serve as a barrier or facilitator, right? The hospital climate, the initiatives that you're undertaking right now, you may just be overwhelmed with the amount of strategies that you're trying, you know, whatever. Right now with the COVID-19 pandemic, probably not a great time to be doing a lot of quality improvement work, right? I mean, yes, we know that it's important, but right now, oh my, the stress and burden of just the sheer increase in demand. But the process of implementation, very important. Who are the people that you have on your team? Do you have the buy-in from the administrators? Do you have those resources necessary? The bundle itself, right, that intervention itself, those parts that you can adapt and the parts that you can't adapt. If you, again, go tweaking with the interventions too much, don't expect to see the same outcomes. So if for some reason you choose, oh no, we're not going to do, we're going to have 10 things on our list, our safety screen, because we're scared to do it on that, or our patients are different. You know, every ICU thinks their patients are the sickest. Every ICU thinks they have the most alcoholics or drug abusers, and it's not applicable to their patients. Every hospital. So I know you're thinking that, well, this will never work because we have all of our patients are drug addicts or alcoholics or blah, blah, blah, and we can never do this. Every ICU thinks that, not alone. But changing the actual evidence too much will impact whether or not your patients have those better outcomes. So be very careful with adapting anything too far beyond the way it should be done, or the way, not should, but the way it's been done before, because again, if you tweak it too much, you're not going to have the same outcomes, and it gets too confusing. The barriers and facilitators, again, of ABCDF bundle implementation are well-described. You can probably write them down on your list right now. Here's some ABCDF-related specific papers that discuss some of these barriers, in particular number, I think it's 16 and 17 on that list, Stallings and Ballas. They specifically report on the biggest barriers and facilitators that we found, but importantly give you some suggestions on overcoming them as well during the ICU Liberation Collaborative. But again, great work by a number of different people in this area about trying to come up with ways of empowering you to be successful in your ABCDF bundle implementation efforts. So I appreciate the time we've spent. I would love to connect someday if you have questions. I'm sure you have a ton of questions regarding this. Feel free to reach out to me. If not, I hope to see you all in Puerto Rico next year at the SCCM convention.

Dr. Michelle Vallis

Ohio State University College of Nursing

ABCDF bundle

mechanical ventilation liberation

ICU-acquired delirium

patient outcomes

ICU Liberation Collaborative

implementation strategies

ICU care