It's my honor and pleasure to be presenting to you today. My name is Karen Chung, I'm a Pediatric Intensivist from Hamilton, Ontario McMaster in Canada. You've heard from my esteemed colleagues a really great summary of how to implement the different aspects of the bundle. And I'm going to talk about how to optimize adoption and sustainability of the A2F bundle in your units. I'm gonna start with my take-home message. For us to optimize the adoption of ICU liberation is to think about it not so much only as a bundle or practice guidelines, but to think about it as standard of practice and expected practice for your institutions. It requires us to think about ICU liberation as decreasing patient harm and improving patient safety. It requires us to think about ICU liberation as improving the quality of care. What is quality of care? Quality of care requires us to think about how we're doing something, our process of care, the delivery of that care to our patient. And improving that care requires us to think about the change that is required to do something better. My apologies for some of the formatting issues that were lost in translation. But in healthcare, the quality of care is defined by these six components. How effective that intervention is, is it safe, is it patient-centered, is it efficient, is it timely, and is it equitable? And so patient quality and safety is big business for our hospitals and institutions because it is linked to patient outcomes, but it's also linked to patient costs and it's linked to patient satisfaction. And so our hospitals, our institutions, invest in patient safety officers and quality improvement personnel. They promote patient safety champions and they require us to take regular patient safety training. Our hospitals are required to transparently report on key quality and safety indicators, known as key performance indicators. And these are linked to resources, resource utilization, and remuneration. And so these key performance indicators are set by the hospital and they're typically similar amongst different hospitals. And they include bed occupancy rates, wait times, length of stays, and the clinical outcomes that are linked to these resources, such as mortality rate and adverse event rates. Also included are hospital-acquired infections. And you can see these are the top five hospital-acquired infections that we're required to pay attention to and we're all aware of these and familiar with these because they affect us in the unit. Ventilator-associated pneumonias, central line-associated bloodstream infections, and catheter-associated urinary tract infections. And you can see why these are important. Key performance indicators because these five major infections cost the US hospitals $9.8 billion in 2012. Our PICUs and our ICUs also have key performance indicators. These may be influenced by our institution, but they're also often influenced by regional, or in our case, in Ontario, provincial requirements. That allows us to benchmark against our other colleagues and ICUs in our region. As an example, in our ICU, you can see our key performance indicators are similar. There are these hospital-acquired infections, such as VAPs and central line bloodstream infections, and the unwanted adverse events, such as unplanned extubation, medication errors, and resource utilization, such as the length of stay. There may be external drivers to your key performance indicators. Some of your institutions may be members of Solutions for Patient Safety. Solutions for Patient Safety, or SPS, is a collaborative network whose mission is to eliminate serious adverse events and hospital-acquired complications across all children's hospitals. You're required to subscribe or have a membership to SPS, and there are at least 144 hospitals across North America now working together, and this provides a mechanism by which we can share methodology to decrease harm in our hospitals. You can see on the SPS mandates, the list of HACs, hospital-acquired complications, are similar to the key performance indicators that I showed to you before. The important point here is that having key performance indicators work. Having standards that are driven by leadership and hospital administration actually are major drivers for knowledge translation and practice standards in our institutions, as a result of which you can see that these hospital-acquired conditions have decreased, lives are saved, and dollars are saved. I'm going to point your attention to the underlying rate of these unplanned extubations, pressure injuries, and adverse events in children's hospitals. These are the key performance indicators that our units are required to monitor. They are important, but look at the event rates. They are low. They're likely to be lower because we're not intubating patients as often, we're not putting as many invasive lines as we used to. Contrast these to the key PSU-acquired conditions that are the target for ICU liberation. You see the rates here, and then my colleagues have summarized these consequences and their incidence, their prevalence very, very nicely. I will say that 100% of our PICU patients will experience at least one of these morbidities during their ICU stay. This is the magnitude of the conditions that we are talking about. Why are PICU conditions, they're not part of key performance indicators. You heard presented already that they lead to poor patient outcomes. They lead to increased resource utilization. They lead to increased costs. They lead to consequences, not just in the ICU, but out of the ICU. You've heard presented by Dr. Morrow the post-intensive care syndrome. These have direct consequences and cost to the patient that are sustained well long after they leave the ICU and also to the medical system. We have a solution. We have an evidence-based bundle that is targeted specifically to decrease these acquired harms. The ICU liberation bundle, I say is the poster child for quality improvement because it fulfills every single one of their criteria that defines quality of care. You've heard presented that it is efficacious. It is effective. It is safe. It decreases harm. It is patient-centered. It is family-centered. It is sufficient. It is timely, early for everybody, and it is equitable. So why hasn't it made it to key performance indicators? In fact, we have evidence from as early as 2012 that it should be. The systematic review showed that the routine assessment of pain and the routine assessment of sedation level should be included as key performance indicators for ICUs. Another study published in 2009 showed similar findings, but they showed that the lack of routine pain assessments and the lack of sedation level assessments was associated with increased mortality and increased length of stay. You've heard very nicely presented guidelines, pediatric guidelines. These have been published now for over several years. Are pediatric guidelines enough to change practice? You heard nicely summarized by the PARCC-PICU study that despite having several iterations of practice guidelines now published, both in adults and pediatrics, the uptake and the adoption of the liberation bundle is challenging. That is true not only in pediatrics, it is also true in adults. In this international study, they showed that less than 50% of the 135 units involved had guidelines. Practice guidelines are not enough to deliver the care to the patient, and you can see the rates here summarized that the actual delivery of these components to the patient was much, much lower than even the rate of having a guideline in their unit. You heard Dr. Zimmerman talk about waiting and the waste of waiting, and this oft-quoted evidence that it takes at least 17 years for clinical practice to translate, evidence to translate into clinical practice. What's concerning is that the evidence suggests that it may take even longer to de-adopt unnecessary practices. That is concerning to me because the liberation bundle is all about de-adopting practices that have been steeped in tradition. We know that ICU liberation bundle sustainability is challenging. The COVID-19 pandemic has shown this to us with the resurgence in immobility, excessive sedation, and restrictive family presence, policies mandated by institutional leadership with the best of intentions, just bearing in mind what leadership can do to the undoing of practices for which there's evidence. So, with that in mind, my task now is to show you why ICU liberation is the poster child for quality improvement. We now, fortunately, have evidence on implementation of ICU liberation. We know the factors that influence adoption into practice. Dr. Bettis said that it's difficult. Implementation is difficult. I would say now we have accumulating evidence how to make what is difficult easier. We now know what the barriers and facilitators are, and what is interesting is that the barriers and facilitators are actually common amongst institutions. They're common amongst both pediatric and adult ICUs. So this is the evidence that we've now gathered, not just from our own studies, but our own implementation studies, but others, and I hope to summarize these for you in the next few slides. The first barrier is our unit culture and practice. You've heard this say that the unit readiness for change or reluctance to change is what often influences practice. What the common barriers are, in fact, is us, clinicians, doctors, how we practice. We were at a focus group the other day, and that was one of the recurring themes of how clinicians are inconsistent in applying the bundle. We're reluctant to change. So how can we create clinician buy-in? First and foremost is we need to view rehabilitation and the ICU liberation bundle not as research, but standard of practice. How do we do that? Make sure you embed this as an expected requirement in your unit. We include pain scoring, level of consciousness assessment, delirium scoring, mobility risk scoring, all those things that are required in your liberation bundle as vital signs. These are not optional, they're mandatory. Not just asking your clinicians or your nurses and your allied health to do these vital signs for you, provide them with the value. You ask your nurses to tell you what the blood pressure when you're treating a patient with septic shock, you ask them what your saturation levels are when you're treating a patient with ARDS. These vital signs should be reported on every single patient, every single day, at every single opportunity, and also a nursing expectation on their transfer of accountability. Ensure value, use these to generate a discussion and a team collaboration in the patient goals and plans every single day. Again, we target blood pressure when we're treating septic shock. We should be targeting outcomes of pain assessments, level of consciousness assessments, delirium scoring, et cetera. The next barrier, a common barrier you've heard before, nurses, RTs, not often physios I would say, are really scared to mobilize patients. They're scared to decrease sedation, they're scared to allow awakening. We need to educate not just the clinicians at the bedside, but also the patients and families. As you've heard before, they are your strongest ally, but they also have reservations because they're spending a lot of time with your bedside nurse. Educate both the nurses, clinicians, and families that ICU liberation is about decreasing harm because it's about improving patient safety. Educate them about what we talked before. We spend a lot of time trying to minimize these key performance indicators, CLABSI, unplanned extubation. We should be paying equal attention to decreasing these common harms in terms of iatrogenic withdrawal, delirium, sleep disruption, and parental stress. You've heard the data summarized for you that the ICU liberation bundle and early mobilization is safe, the systematic review evidence for it, but we now have evidence from our implementation study that it decreases toxic exposure. Implementing an analogo sedation approach decreases exposure days. Implementing a benzodiazepine sparing approach not only decreases benzodiazepine exposure, but in our Bi-Center study, we showed that it actually decreases all classes of sedatives. I found that quite interesting and impressive. Clinicians are afraid about awakening and mobilizing children, including the infants and toddlers. We now have implementation evidence. This is a time series analysis, and you can see for yourself, wakening up a patient, decreasing sedation does not increase pain or discomfort. In fact, it improves it, and awareness, and your ability to assess their pain, and it also does not increase adverse events. It does not increase unplanned extubation or falls. Concerns about nursing workload. We're asking our nurses to do these. Are they really complex assessments, delirium assessments, pain assessments? We're asking them to get them out of bed. Nurses are afraid about increased workload from the ICU liberation bundle. We now have implementation science evidence that it does not. Nursing workload is not increased. If anything, I would say, well, actually, not if anything. I have it up there on the slide. This evidence that shows that it improves interprofessional team collaboration because you're working together to do it. You heard about cost savings. Cost savings because you're decreasing morbidity. There's actually evidence out there that it improves or saves costs from healthcare provider injuries. When you're getting these patients up, you're not actually causing more harm to the healthcare provider either. How do we ensure delivery and sustainability? How do we ensure that we deliver the ICU liberation bundle to every single patient every single day? Again, this is evidence informed from implementation study, implementation study. The first is don't just take somebody's guideline. Tailor that to your unit. Each unit is different. Your patient population may be a little bit different. Tailor it to your unit's needs by including input from your team and input from your families. You've heard that family engagement is key to every single aspect of that bundle. If you engage your team and your families into tailoring that guideline for you or those guidelines for your unit, it encourages team ownership. Make sure you embed order sets. Embed the practice into your order sets and make sure that your order sets are educational. Education, you've heard about education in every single aspect of the bundle. My comment about education is as follows. Mandate it. Don't just make it one training day. Don't just make it, although very excellent, a training session at the SCCM. Make sure you embed a mechanism to deliver that education regularly in your unit because you've heard the turnover of not just nursing staff, but clinicians, physicians, trainees is high in your unit. Develop a mechanism that encourages regular education. So we embed it in our syllabus. We mandate it. We require that our clinicians are recertified regularly on ICU liberation. Make sure your education is point in time. You've heard about that in terms of high functioning or pre-arrest patients. I would say look at the opportunity as clinicians to educate on ICU liberation on every single patient as you're rounding on them every day. Ensure that you have accessible educational resources and decision support, whether that be through low cost technology or through a handheld or through electronic health records. We used a low cost, low tech glass door to transparently display patient goals for those vital signs. We found that we've adopted Epic into our healthcare system. And what we found that while there are documentation standards within Epic, it is not a replacement for verbal team communication. And so we use a glass door to encourage daily goals checklist. And what we found that it actually increased compliance and increased the rate that every single aspect of those bundles, that bundle was discussed at rounds. Make sure that it's not just at a patient level, but at a unit level. So we have daily team huddles when we talk about patients who are on pad alert, patients who are at risk of delirium, at risk of immobility. Have process observations, meaning involve your unit staff in monitoring for compliance. There are easy ways of doing that. Have liberation champions. You've heard what a long way that having a champion goes. We call them safety champions because we're improving patient safety and decreasing patient harm. Celebrate successes. Photo ops go a long way. Parents love it. In fact, it empowers them. They want to celebrate the success of their child. These anecdotes, we learned in our focus group the other day, is one of the most powerful motivators to get buy-in. If a nurse has experienced somebody with delirium, if a nurse has experienced being able to mobilize somebody, that is a very, very powerful mechanism for knowledge translation. Last but not least, I started with leadership and I'm going to end with leadership because I believe this extrinsic factor, meaning extrinsic to the unit, your hospital and leadership institution is one of the most powerful and important drivers of knowledge translation and resource utilization. So lobby for change in your unit through leadership, but understand what you're asking them for. It may be different for your different units, but I think there's some general things that we should be asking our leadership for that you heard already presented. Number one, we need to make sure we have a documentation standard. Ask for the liberation toolkit, the minimum data set to be embedded and an expectation as a documentation standard in your unit. Know who your patient safety officer is because they have access to this data. They know how to generate compliance. These are run charts. These run charts are being generated for every single one of those key performance indicators that I showed you earlier on. Lobby to have resources dedicated for them to pull this for your unit because your unit staff respond to data. They love seeing improvements. It drives and motivates them. Compliance is not alone, alone is not important. Performance is what is important. If you collect the minimum data set on liberation, you'll be able to generate these compliance data and these outcomes data for the proportion of patients who have a delirium, for example, your length of stay and so on. Use this to lobby these liberation outcomes as key performance indicators for your institution. We talked about external drivers. I think we should be lobbying to solutions for patient safety to include delirium as a hospital-acquired condition because it is, it is not unique to the pediatric ICU. There are other children in your pediatric institutions, for example, oncology patients at very, very high risk of delirium. I choose delirium because it's tangible. There's a distinct data point. There's a diagnostic criteria and it ties everything together. Solution for delirium is the whole ICU liberation bundle. And with that, I hope I've convinced you that ICU liberation is the poster child for quality improvement. I also believe that ICU liberation is solution for quality of life improvement and improved functional outcome in our patients and thank you very much for your attention.

ICU liberation

ABCDE bundle

quality care

key performance indicators

clinician buy-in

sustainability