Well, good morning, everyone. Happy Tuesday, last day of Congress. My name is Pat Poza, and along with Erica Setliff, we're going to be moderating today's session, 10 Years of Liberating Well, Advancements and Learnings from a Decade of Implementing the ICU Liberation Bundle. So the objectives for this session, upon completion, you should be able to describe updates and advances in the literature over the past decade of implementing ICU liberation, the A-F bundle, in critically ill patients. Also develop a plan for leadership buy-in to implement the ICU liberation bundle, and then learn strategies to overcome barriers and implementation of the ICU bundle. We want this to be interactive, so we're going to have questions come at the end, and we're going to leave a lot of time for those, because we want to hear from you. What are your struggles? What are your barriers, or what strategies you've found effective? So we have an esteemed faculty here today. Myself, I'm a Quality and Safety Program Manager at the University of Michigan in the HMS Sepsis Initiative. Erica Setliff is a Clinical Nurse Specialist at Atrium Health in North Carolina, and we have Dr. Matt Ulrich, and he is a Senior Physician Executive at the University of California San Francisco Medical Center. Chris Permay, who is a Rehab Education Specialist at Houston Methodist, and Michelle Rassen, and she is our Respiratory Therapist, and she's the Technical Director of Respiratory Therapy at Sloan Kettering Cancer Center. So welcome to all of you, and we're excited to get started. None of our faculty have any disclosures related to this topic. I'm going to start off with a brief timeline of ICU liberation for those of you that might be familiar with it or not familiar with it. And this timeline is really not written anywhere, but when you see the slides, that QR code takes you to a Wes Ely presentation at the SCCM in Hawaii in 2017. He tells the great story, and I've tried to kind of summarize that story as I've lived along with that story. So we started our journey in adding letters or creating the letters to science, first started in the late 1990s to early 2000s with spontaneous breathing trials and the spontaneous awakening trials. Now that spontaneous awakening trials were called sedation holiday back then, right? So that was the initial work that was done then. In 2008, they combined the awakening trial with the spontaneous breathing trial, and that's the ABC, and that was the beginning of the bundle, right? So now we have A, B, and C. As the researchers doing both the spontaneous breathing trials and spontaneous awakening trials, they found some difference in outcomes related to older patients, and they took a deeper dive, and they saw that delirium was a component in those patients. And so they began doing studies on delirium and created the CAM-ICU at that time, validated that CAM-ICU for the adult population, and found that delirium was independently a predictor of mortality, an independent predictor of mortality, increased length of stay costs and long-term brain dysfunction. Also at that same time, Dr. Kress, as well as Dr. Bailey and Schweitzer from Chicago, as well as in Utah, were doing study on mobility. And the Schweickart study that was published in 2009, they did the ABC part of the bundle before they did mobility, so combining all of them. So now we have A, B, C, D, E. And in 2013, we have the updated PAD guidelines. And that was really where our 10 years is starting, right? So we're in 2023 now. We started to see outcome studies of the bundle in 2014. Michelle Ballas and her group at Nebraska studied the A, B, C, D, E bundle and found that the patients were off the ventilator three days sooner and also showed improved survival, so mortality benefit. Then there was work done both at Hopkins and in the Michigan ICU Keystone Project that again reinforced the positive outcomes of the A through E bundle at that time. Mary Ann Barnes-Daly then conducted a significant study, and they added the F. Their study was funded by Gordon and Betty Moore. Gordon Moore had been an ICU patient and had delirium, and the family wasn't allowed to be in the room with him. And so in the funding, part of the requirement was, hey, you need to have a focus on family, and so the F was born. And so they studied the A through F, Barnes-Daly, and using it as a way, as an implementation arm of the PAD guidelines from 2013. And they found significant improvement in multiple outcomes for our patients, and they found a dose-related response, so that every improvement, 10 percent improvement in bundle compliance significantly improved mortality and other outcomes. The Society of Critical Care Medicine launched the ICU Liberation Collaborative in 2015, and that's when the ICU Liberation Committee was also started in SCCM. The results of the ICU Liberation Collaborative, it was multiple hospitals, 68 hospitals over a 20-month period, and those results were published in 2019. And we had an updated to the PAD guidelines, and they now added immobility and sleep because of the importance of mobility as well as the importance of sleep. And then in 2022, the pediatric guidelines were published. So that kind of gives us a little bit of a history of how we got here today and why we're talking about ICU liberation at 10 years.

ICU Liberation Bundle

A-F bundle

critical care

implementation strategies

patient outcomes