Well, good morning, everyone, and thank you for choosing this session to attend out of many that are available. I'm going to kick this off by talking about what happened during the early years. So how do we make this go? Okay. So the learning objectives are shown here. I want to talk a little bit about quality improvement, a little bit about implementation, but you're going to get all the details of that later. But I do want to emphasize this idea of a bundled approach. That's really key for ICU liberation. My main message, ding, ding, ding, just pay attention to this one. There is a huge impact of this intervention that I don't think people are aware of but should be the burning platform for why we go forward on this. And then close with some comments about waste, weaning, the shift in cost, and sustaining. So there are a number of risks for adverse outcomes following critical illness. And of course you would think, and it is true that chronic comorbid conditions are key here. What the admission diagnosis is and what the severity of illness is when these kids come into our ICUs. And of course the intensity and the duration of organ failure. That's what we do in the intensive care unit. But what ICU liberation is about is about how we provide our critical care. Because it's lifesaving, there's no question about that, but it is fraught with all kinds of potential adverse events because of the way we provide our care. And that's what ICU liberation is all about. So just some facts. This ICU liberation campaign was launched by SCCM in 2014 after publication of the PATHIS guidelines, which really provided recommendations for addressing pain, agitation, delirium in the adult intensive care unit. So this was a large multi-center collaborative organized by SCCM. And the point of this was that the bundle, the ABCDEF bundle, really represented the implementation strategy for each of the recommendations, main recommendations in these PATHIS guidelines. So key elements in all of this was that this was a bundled approach to quality improvement in terms of usual care for critically ill patients. Examples of this in our own world where the sum of the bundle works better than individual elements practiced individually is the CLABSI collaborative, huge impact on reducing childhood deaths in the United States, and more recently the Pediatric Surviving Sepsis Campaign, both good examples of bundled care. To do this, you have to have a team, an interdisciplinary team, participating in this. And I would add, and I think this is very important, that these team members ideally should be practicing at the top of their skill set. The docs shouldn't be micromanaging everything that everybody does. Very key point, I think. And then lastly, this whole approach strives for a patient who's more awake, alert, interactive, and actually engaged in the care plan. So this approach, ICU liberation, takes this focus of critical care medicine, which is on organ dysfunction and resolution. Again, that's what we do in intensive care. And with this new approach adds this holistic element of care to the way we provide it in the intensive care unit. This is known as ICU liberation. And my view of this is, this is clinical standard work for the usual care that is provided to all critically ill and injured patients. So the PICU collaborative came about, had a lag time of about a year, year and a half from the adult group. Initially, there were nine hospitals involved in this. And I would say for sure that when we started, there was completely variable degrees of knowledge, implementation, and performance, for sure, of each of the six bundle elements. To be in this collaborative required buy-in not only from ICU leadership, and another key point, but buy-in from hospital administration in general, interdisciplinary team, again. And then SCCM set up these educational sessions where the nine teams met monthly, virtually sometimes, in person sometimes, to discuss barriers and successes for implementing PICU liberation. So here's the bundle. Everybody's heard of this. And I just want to reiterate quickly, A, always assess and treat pain. B, both spontaneous breathing and awakening trials daily. The pediatric interpretation of this is a little bit different from adults, and you'll hear about why that is. The choice of drugs that we use for analgesia and sedation. D is management, prevention of delirium. E is early mobility and exercise. And F, of course, engagement, empowerment of the family in the care plan whenever it's possible. Here's just some kind of highlights from what was going on in this initial PICU collaborative. Started off in March of 2015 with an in-person meeting, and we were fortunate to have, I would say, several in-person meetings as we went along. In 2016, things actually got going. The specific aims, the inclusion-exclusion criteria for this initial pilot trial were confirmed, the data collection and the database finalized. The intervention phase, when hospitals started tracking performance of the bundle, began in October of 2016, and the intervention phase ended in June of 2017. Meanwhile, during this time, the very initial results of this collaborative were reported at the SCCM Congress in 2017, and then ensued a process of complex statistical analysis, manuscript composition, recomposition, recomposition, but I can tell you with assurance that I think the final iteration of this will be submitted today and hopefully available soon for all of you to read. So I'll begin with this slide. This is very important, and this is what I don't think people know, that they need to know. The y-axis is the proportion of bundle elements performed. This is one of two very important adult studies, but this is the outcomes, ICU discharge alive. The second, alive and discharged from the hospital, and then the third, overall decreased risk of mortality. In a dose response fashion associated with performance of the ICU liberation bundle elements. Now if you look at these odds ratios, I would challenge anybody to show me any study that has ever been more impactful in terms of outcomes for critical care. This is what our message should be in order to get all of this up and going once again. I can tell you that there is also a very statistically relevant impact on decreased mortality in the pilot PICU liberation study, a dose response association with improved mortality. However, the relationship to performance of individual bundle elements with that outcome is not nearly as strong as the adult data. So overall, there's nice evidence, particularly in adult studies, but some coming out in pediatrics, that performance of the bundle is associated with improved patient-centered clinically meaningful outcomes. Almost any one of them that you can think of, but including survival, duration of mechanical ventilation, freedom from delirium and coma. When you leave the ICU, you have less risk of being readmitted. You actually need less restraints. And when you leave the hospital after you survive critical illness, you actually have a greater chance of going home rather than to a nursing facility. So let me talk about this in closing, as I get close here, waiting is the biggest waste in medicine. We wait for things all the time before we do anything to act. It's just a fact. So in my view, the unwritten engine of ICU liberation is weaning, weaning the ventilator, weaning the sedation and minimizing the time that the patient is immobilized. It's proactive, not passive when we get around to it, but proactive, even scheduled maybe weaning will reduce this waste of waiting. And by reducing the waiting, the value of our care will increase not only because quality improves, but this waste of waiting will be decreased, and that's increased value. Now with this, there's a shift in cost. Right now, a lot of the way we provide care is centered around pharmacology and specific medications that have their own adverse effects, costs that are important. With ICU liberation, there is this alternative focus away from pharmacology and to people. People beginning at the inside core with the patient, but a whole host of people that are valuable for distracting the patient, providing sedation or comfort, if you will, and then engaging them in exercise and mobility. And so the cost shift is from drugs to people, and that may be a difficult cultural change for many places to swallow, it's just a challenge. So in summarizing here, what happened in the early days that has informed where we are right now is that there are strong adult and emerging pediatric data that says this works, and it is not a subtle effect, it's real and it's impactful. Weakness is not really weaknesses, but certainly challenge is that there are personnel needs to make this work. The personnel is a multidisciplinary team doing what all of them do best, but getting there takes some convincing, it's implementation science, it's culture change. The opportunities are clearly within this electronic health record. You can take this ICU liberation bundle, tweak it a bit for whatever, embed it in the electronic health record, and there you have your database for your quality improvement, continuous data flow to show what is happening. The threats are significant. There are competing quality improvement initiatives. After COVID, after this is our COVID, the current viral epidemic, we have less ICU staff, we have younger staff, we have less experienced staff, we have nervous staff that need to be encouraged that still this is the right thing to do. And then lastly, it's easy to implement and get things going, but it is a task, it is work to sustain any quality improvement effort. So with that, thank you very much for your attention, look forward to your questions as we move through the session. Thanks very much.

ICU liberation

intensive care units

bundled approach

patient outcomes

multidisciplinary team