Good afternoon, everyone. This is a great turnout for this very important session. We really all appreciate the fact that you showed up this afternoon and everybody seems to be awake, so yay. My name is Dr. Julie Barr, and it's a pleasure for me to be here today to present this latest study demonstrating the value of the ABCDEF bundle in improving ICU patient care and outcomes across a large healthcare system. I have no financial disclosures in this instance, and prior consent was obtained for all pictures of VA patients depicted in this presentation. When I began my career as an intensivist over 30 years ago, the standard of ICU care was deep sedation and prolonged mechanical ventilation for our sickest patients until they got better. Over time, we came to understand that deep sedation and immobility comes at a price and actually worsens ICU patient outcomes, resulting in delirium, ICU-acquired weakness, prolonged mechanical ventilation, iatrogenic complications, longer ICU and hospital lengths of stay, worse long-term outcomes, and death for many patients. In 2013, the Society of Critical Care Medicine published the Pain, Agitation, and Delirium Clinical Practice Guidelines, also known as the PAD Guidelines, and launched the ICU Liberation Campaign to help promote these guidelines. In 2018, SCCM published an updated version known as the PADIS Guidelines, which emphasized the importance of promoting early mobility and sleep in critical ill patients as well. As part of the ICU Liberation Campaign, the ABCDEF bundle was created to help translate these guideline recommendations into clinical practice. The A-F bundle takes an integrated approach to managing pain, sedation, and delirium in critically ill patients in order to facilitate ventilator weaning in mechanically ventilated patients, early mobilization of all ICU patients, and patient and family engagement. To date, three large studies have demonstrated that bundle performance is consistently associated with significant decreases in the probability of next-day deep sedation, delirium, and restraint use in patients, prolonged mechanical ventilation, ICU readmissions, hospital mortality, and SNF discharges in ICU survivors. Bundle performance also has a dose-response effect on these clinical outcomes. As bundle performance improves, these outcomes improve as well, with a 60% bundle performance rate being a significant inflection point for these outcome improvements. Other studies have shown that bundle performance is also associated with significant decreases in both ICU and hospital costs. Shea and colleagues demonstrated a 24% decrease in ICU costs and a 30% decrease in hospital costs with only partial bundle implementation. A more recent study by Fish and colleagues showed that bundle implementation in a single 24-bed medical-surgical ICU significantly reduced the duration of mechanical ventilation and ICU and hospital lengths of stay in patients. This saved the hospital over $1.6 million annually and $4.3 million over a five-year period following bundle implementation. In 2013, the Dignity Health System, now part of Common Spirit Health, conducted a multi-center prospective observational pilot study with grant funding from the Moore Foundation. The goal of this study was to implement the ABCDEF bundle over a 12-month period in 11 adult ICUs across six community hospitals in Northern California in mechanically ventilated adult ICU patients. The Moore grant provided partial salary support for one year for a study coordinator, a physical therapist, and a physician champion at each hospital. Dignity Health had previously implemented some elements of the bundle, including pain management protocols, SAT-SBT trials, and routine ICU family meetings. The goal was to ultimately spread the entire A-F bundle across all ICUs within the Dignity Health System. The pilot study included all adult ICU patients admitted for more than one day to these 11 ICUs, although only mechanically ventilated ICU patients were targeted to receive the full bundle. Patients with an ICU length of stay of longer than 30 days, baseline mobility limitations, and patients receiving end-of-life care only were excluded from the study. There were six phases to this study, including a 12-month baseline phase, a six-month bundle implementation phase, a three-month baseline bundle compliance phase, followed by a 12-month bundle performance phase, a healthcare system bundle implementation phase, and a 12-month sustainability and spread phase. Patient demographics and outcomes were assessed only in the six-pilot study hospital during the baseline and performance periods in both mechanically ventilated and non-mechanically ventilated patients. Patient outcomes included ICU and hospital length of stay, duration of mechanical ventilation, the percentage of ICU patients with lengths of stay of a week or more, and hospital mortality. Bundle compliance metrics were measured at baseline following implementation and throughout the implementation phase in the same six study hospitals. Then modified bundle compliance metrics were measured during the 12-month sustainability and spread phase across all 34 Dignity Health hospitals. From 2015 to 2018, several changes were made across the 34 hospital healthcare system to facilitate bundle spread and sustainability system-wide. These included full integration of bundle metrics into their Cerner EHR platform, creation of bundle order sets, creation of bundle performance and outcome reports using aggregated EHR data, and making the A through F bundle a healthcare system priority with strengthened leadership support and greater resource allocation towards bundle QI efforts. Of note, these healthcare system changes were all made without any external funding support from the Moore Foundation or another entity. So what did this massive effort to systematically implement the ABCDEF bundle across the entire Dignity Healthcare system achieve? The size and type of the six community hospitals in the pilot study and their corresponding 11 ICUs that participated varied significantly. They included urban, suburban, and rural community hospitals, ranging in size from less than 125 beds to over 250 beds. ICUs ranged from 80 to 40 beds and included medical, surgical, trauma, and cardiac ICUs. Approximately 12,000 patients were admitted to the 11 study ICUs during the baseline and performance periods. Eligible patients included over 1,900 mechanically ventilated patients and over 3,000 non-mechanically ventilated patients. There were no significant differences in the demographics of the baseline and performance groups of either cohort. Total implementation in mechanically ventilated patients was associated with significant reductions in ICU length of stay, duration of mechanical ventilation, and the percent of patients with an ICU length of stay of a week or more. Average ICU stay decreased by 0.5 days. Average duration of mechanical ventilation decreased by 0.6 days. And the percentage of patients with an ICU length of stay of more than seven days decreased by 18 percent. There were also trends towards reductions in hospital length of stay and in-hospital mortality, but these differences were not statistically significant. By contrast, there were no significant improvements in observed outcomes in non-mechanically ventilated patients. Compliance with individual bundle elements varied during the performance period. Benzodiazepine management and SAT-SBT trials were high at baseline and did not change over time. Reintubation rates did not increase with bundle implementation. Sedation assessments significantly increased while the use of benzodiazepine infusions decreased. Delirium assessments increased while delirium prevalence decreased. Benzodiazepine mobility assessments actually decreased, and the percentage of patients achieving a mobility score of two or more did not significantly change. And family engagement did not change. Three years after the initial study was completed, bundle sustainability in mechanically ventilated ICU patients varied across the six study hospital ICUs. SAT-SBT compliance had decreased by nearly half over time, while compliance with sedation and delirium management and the preferential use of non-benzodiazepine infusions for sedation remained high. Daily assessment and mobilization of mechanically ventilated ICU patients remained low, and routine ICU family meetings actually decreased over time. There was significant bundle spread to other ICUs across the healthcare system, however. Compliance with bundle elements in the ICUs of the 28 non-study hospitals was generally higher than in the study hospitals. A similar pattern was seen in bundle elements compliance in these hospitals, with high compliance rates for sedation and delirium management and non-benzodiazepine use, and lower compliance rates for SAT and SBT trials, early mobility, and family engagement. So what did we learn from this study? Similar to the observations of previous large A through F bundle studies, significant improvements in ICU patient outcomes were seen in this study, with only partial bundle compliance. We observed a strong correlation between improved sedation and delirium management and decreased benzodiazepine use, and an observed decrease in delirium prevalence in this study. The lower compliance rates in this study for SAT and SBT trials, early mobility efforts, and family engagement may reflect the greater need for interprofessional team communication, collaboration, and care coordination to execute these particular bundle elements. Previous studies have shown an improvement in ICU patient outcomes in both mechanically ventilated and non-mechanically ventilated patients. In this study, non-mechanically ventilated patients were not targeted to receive the full bundle, and no outcome improvements were subsequently observed. Providing real-time system-wide IT support to fully integrate the bundle into the EHR platform and to provide real-time dashboard-driven data analytics helped to facilitate bundle sustainability and spread across the entire healthcare system. Strong leadership support for bundle implementation by making it a healthcare system priority and by allocating the necessary resources to bundle implementation efforts helped to accelerate bundle adoption across the entire healthcare system. This is now the third large multi-center study demonstrating significant improvements in ICU patient outcomes following bundle implementation. But unlike previous studies, this study quantified the cumulative impacts of the bundle on ICU patient outcomes and demonstrated successful spread and sustainability of the bundle across a large healthcare system outside of a one-time quality improvement project. The ICU liberation value proposition is that the ABCDEF bundle improves ICU patient care and outcomes and reduces healthcare costs by optimizing pain, sedation, and delirium management to facilitate ventilator weaning and early mobilization of ICU patients and to increase patient and family engagement and care. Even partial bundle performance significantly improves patient outcomes and reduces healthcare costs, yet many hospitals and healthcare systems have yet to fully implement the A-F bundle, citing staffing shortages, EHR limitations, and costs. ICU providers and leaders must partner with hospital and healthcare system executives to make the business case for ICU liberation. Thank you for your attention and time.

ABCDEF bundle

ICU patient care

Dignity Health System

EHR integration

implementation barriers