So, we're going to move into our panel discussion, and as we do so, I wanted to just level set for this group why we chose some of the topics that we did. At the end of 2022, the ICU Liberation Committee through SCCM did a needs assessment of our members to say where are we and what should our priorities be for supporting you in implementing the bundle. So, 197 clinicians, mostly physicians, followed by nurses, and 259 leaders responded, 30 percent of those leaders did have direct patient responsibilities. This was mostly representative of the U.S., and community hospitals and academic medical centers were our highest number of responders, with, on average, 28 and a half ICU beds that they supported, a median of 20, and the graph that you see on the side just shows most of this was adult-focused, but we do recognize there's so much work going on in pediatric liberation right now, has been for a long time, leading up to the Pandem Guidelines publication, and just really strong, ongoing work there. So, some of the responses were mixed, but when you bundled them all together, about 90 percent of the people had some responsibility for adult ICUs, about 15, 16 percent in peds, and a little bit in neonatal. Some of the highlights there, only 12 percent of the clinicians and 22 percent of the leaders indicated they had an executive sponsor for liberation, and so I think that when we as a committee look at what are the things that need to be part of our focus, how do we really bridge that gap? So, we're going to talk a little bit about leadership buy-in. Only a third said, I see liberation implementation aligned with their hospital's strategic goals, and I think we all know it does align with your goals if we make it align. Everybody's looking at cost savings and reducing length of stay, and cost consumption in the post-discharge space, and all of those things, so liberation certainly affects all of that across the continuum, but we probably could be more intentional about linking those outcomes and helping to bring that into the strategic planning for support. And then data-driven compliance, only 32 percent indicated that they measured bundle compliance in their institutions, and about half of what was left said they didn't know. You know, it was no and then don't know, but to me, if you don't know if it's being measured, then functionally it's not measured for you if it doesn't get to the end clinician. So self-reported unit compliance, just to Matt's points, and certainly what everyone in this room has experienced, there was a reported post-pandemic decline in bundle implementation, although I did see a few responses that showed they felt they were doing better post-pandemic, and I think that we can probably capitalize on some of that momentum that people want to get away from sleeping sad patients on the ventilator and families who aren't part of our care and the outcomes that go along with that. So I think that there's some really good momentum that we can capture as a profession and as, you know, a service line to really improve care for our patients. What was interesting was when we looked at the implementation barriers that were identified, the clinician and leadership responses, the number 1, 2, 3, 4, and 5 were the same in the exact same order. So interesting to see that we all are understanding and seeing some of those barriers the same way, lack of staffing being a primary driver, lack of education and staff buy-in, leadership buy-in, and communication breakdown showing up strongly. So these drove some of the topics that we selected for today because I think, you know, as a speaker up here, I struggled a little bit looking around and saying, why am I up here because, you know, we have the people here who have driven this research and are the publishers and many of you in the audience are doing this work and doing it well. But I think a lot of us are in this space where we know the research is there and we're trying to do it. How do we do it better? Give us some strategies. We see its importance. We know it's a thing and we're trying to do it better in our organizations. So I think that that's what we're focusing on today with the last part of this is what are some of those strategies and how are our teams doing it well? So our first topic for the panelists is buy-in from leaders and clinical teams. So do we have mics ready to go? Thank you. Thank you, Steven. He's been great. So I'm going to start with Michelle. And I would like to know, you are working hard on liberation in your areas. So how does it look for you to get that buy-in from your clinical team? These are the people that you're asking to do the work. How do you get them on board? Yes. Thank you, Erica. So it was really important for me at my institution to engage our clinical teams. And so something that we did that I'd like to share with you all is we actually sent out a survey before we implemented our formal SAT-SBT practice. And we sent this survey out to a respiratory therapist and her nurses. And we asked them to share their concerns and their fears around implementing this practice. And their responses really elucidated concerns around timing in doing this. And much like the needs assessment survey, a fear of lack of staff support in responding to potential failed extubations. And just by sending out this survey and engaging them, the staff felt heard and supported. And we were able to have their input in building these processes. And it was just immensely helpful. And it really changed the game for us when it came time to actually implementing these practices and making the decisions surrounding timing. And to actually, you know, assuage their fears about how we were going to address their concerns. That's great. Thank you. Matt, I'm going to ask you to speak a little bit from a leadership and especially electronic health record buy-in, you know, how do you get everyone on board across the continuum when we're asking for resources and time and money and development? So it's a good question. I mean, at UCSF, I think for us, I mean, a couple things happened. I mean, one, for us to join the collaborative, we had to have a discussion with our senior leadership team. And that was part of it. So that, in some respects, was helpful to us because it kind of primed this discussion. We had already been doing a lot of this work. We already had a fair amount of protocols in place, certainly around sedation interruption, mobilization. So I would say we had fairly good executive buy-in. I mean, I do think for any of you who work in a hospital, there's a lot of focus on volume. And now that I'm in a capacity and throughput role, I know how much focus there is on volume and throughput. I mean, so I certainly think that there is an argument. There's a strong rationale here for implementation of this bundle and obviously the clear benefits to patients and families, but I think, frankly, also the benefits to a hospital system that is trying to reduce length of stay. And I imagine at many of your institutions, you're focused on length of stay and length of stay indices, and so is your senior executive team. And so I think this is an area where you can make a strong argument to that team that the resources required to effectively implement the bundle can add value across the spectrum, whether it be hospital-based finances or, I would say, obviously, more importantly, patients and families. The IT and the EMR component is tricky for a variety of reasons. One is because, you know, I'll just focus on EPIC because we're an EPIC institution. EPIC had a number of tools, and we've done a lot of work with EPIC. Initially it was really challenging because we couldn't get a contact at EPIC. And for whatever reason, we talked a lot about this, we couldn't move this along. I think EPIC had other priorities, and really since that time they've been, you know, just as one example, they've been really a good partner with us, and we've done a lot of collaborative work with them in developing tools that are available in EPIC Foundation, and similar work has been done. I don't want to focus on just EPIC, not endorsing one EMR over another, but work has been done with other EMR companies. I think one of the challenges, and I think what everybody needs to do, is recognize that there often are tools that you may be aware of because you come to a conference or you talk to a colleague at another institution, but it's how you get that tool actually to the bedside. How do you get that tool embedded within, whether you have a custom format of EPIC or another EMR, how do you get access to it? And I think the EMR companies often feel like they're doing this content development, and then they're having a difficult time getting that disseminated out to institutions. And that can be tricky because some of the folks at your institution who are doing your EMR work may not be aware of the content or just may have other priorities. I will say for us, we just didn't actually, for whatever reason, we had primarily hospital medicine-based folks who were informaticists and were sort of embedded within our EMR teams, and they were working on discharge issues for the most part. And so we had to align our priorities and recognize that that's important, and improving discharge through various EMR tools is an important goal. We had this ICU-based set of interventions that we were trying to implement, and we needed the help of EMR. So I think it's just, it's awareness. I will say the companies do have access. I mean, you can go to EPIC, for instance, and you can get access to what's available, and you can bring that, literally, a PDF to your IT and EMR teams and say, this is what's available, and this is how we can implement it, and I know this is possible because it's been done at dozens and dozens of institutions across the country. Thank you for that, and we do have a slide later that has QR codes for some of that access for both EPIC and Cerner, because the IC Liberation Committee has done very intentional, very focused work collaborating with those two EMRs, which are the biggest vendors out there, and so thus prioritizing that work. So, Pat, you have built and developed many successful programs in your career. What are some of the things that you've learned from a general implementation perspective that you think are helpful to share as people are looking at that broad-scale implementation? So one of the things that has always been challenging in talking about buy-in, staff buy-in, is to have people understand the why. And so going to the why and making sure that people understand why we're doing this. You know, we have moved in critical care from it's not good enough to just have our patients survive. We need for them to be the same person that they were when they got to us after they leave us. And by sharing with the staff the importance of these practices will help prevent some long-term, that can be permanent, cognitive and functional impact, as well as mental impact on our patients. And so at a number of organizations that I've been at, we had our staff listen to some of the survivor stories that have been here at SCCM as a group, as well as there's lots of patient stories on Vanderbilt's website, www.icudelirium, so that they could really understand that sedation can cause harm, right? Because their mindset was, I'm helping this patient so that they don't feel the uncomfortableness of the ICU. So really being able to help them ground in the why and then doing these interventions then makes sense. So as I'm grabbing to increase the sedative rate, I'm thinking in the back of my mind then, gosh, that can have a negative impact, so let me do something different. So really focusing on ensuring that everyone understands the why behind this. And this just pulls a summary of the why. It's not just helping them survive, but helping them be able to thrive. Thank you for that. I totally concur. I think when I'm teaching, especially my newer nurses and trying to get some of that buy-in, I start with picks and work backwards because I think a lot of our, you know, I'm a clinical nurse specialist. I work a lot with all of our professions, but especially our newer nurses and trying to get them into the culture of what this looks like in practice, they don't see that continuum of the patient six months from now. We know from the literature what it looks like, but most of our hospitals don't have a good measure of how are we doing on picks. At best, we've got ICU length of stay, the short-term outcomes, ventilator days, but we don't see that long-term. And so connecting them to that, I think, is what gets nurse buy-in for sure because we're here to save lives, and saving the life that goes with that patient once they leave our doors I think really does resonate. So Chris, mobility is certainly a hot topic, and I'm curious when we talk about buy-in, my first question and spinoff is what discipline is responsible for mobility? And really along with that, how do you, as a therapist, help people to realize that mobility doesn't just equal consult PT? OK. That's a wonderful way to start. Good morning, everybody. So I'm going to say one sentence, and if you have to remember just one thing from this entire lecture, I hope it's it. Mobility for patients in ICU is everybody's job, period. OK? So I'm going to say that any ICU who relies solely on physical therapists for their mobility program will not succeed. And I am a physical therapist. I am passionate about mobility of patients in ICU. I have spent more than 30 years of my career as a physical therapist inside an ICU mobilizing critical you patients every day. I've never worked as a physical therapist in another setting. I'm passionate about it, but I'm still seeing that if you rely only on physical therapists, it's not going to work. And the reason for that is because, first of all, there are not enough physical therapists trained to care for critical ills, patients available. And also, the resource is limited. We only provide care to patients in a hospital from eight to four. And of course, you probably understand that at least two of those hours we are documenting. So the amount of time that we really have hands-on on the patients is limited. So I am not saying that, for example, you know, it's Matt's job to come and get a patient out of bed. It's not what I'm saying, but I'm saying that, for example, sometimes physicians, they completely underestimate their power as educators. And like, you don't have to physically get the patient out of bed. But if you go to the bedside every day, and you kind of ask your patient, have you been out of bed today? How many times did you get out of bed yesterday? Make sure that the nurse helps you out of bed. Those are powerful words that also are going to encourage the patient and help the patient understand about the importance of that. Thank you very much. And I think you're moderating this next part. So as Erica said, based on the needs assessment, one of the other things we want to talk about and focus on in the panel and hear from some of our experts here is different implementation strategies. How did you do this? What were your barriers? How did you overcome them? So I'm going to start off with Erica. So you work with a large system. What strategies have you found successful implementing the bundle, you know, one unit and as you spread it system-wide? So that's a good question. And I actually have a slide with one of my, one of the models that I like to use. I think something that's unique about liberation is, yes, we need the tools. We need everybody on board. But it's also a culture shift in a lot of ways. And one of the models I really like for approaching culture change is from the team, used to be Vital Smarts, but now it's Crucial Learning. And it's the influencer model or the critical influence model. And really looking at, does each person have the motivation and the personal ability? Socially, do we have the social motivation and the social ability? Structural, do we have structural motivation and structural ability? And I'll actually use this graph sometimes just as a quick touch point when we're looking at whether it's one individual element that we need to work on or broadly as a culture toward liberation as a whole and work through it on a whiteboard or with a team and say, where are our gaps? Are we missing a piece of this? Does each individual teammate have what they need? Do we as a unit have things set in place? Do we as an organization have things set in place to both motivate and provide that structural capacity? So the rest of the model is really incredible as well. I'd encourage you guys to look into this, but really honing in on the vital behaviors of if I could do one, if I could get people doing three things, what are those three things we have to do every day that would get us doing most of where we need to be? And then we can refine the small stuff. But if I can hone in on I need everybody doing these three things, really work through that with your teams. And then, of course, we have to have a way to measure and look at our results. Are we achieving what we want to achieve? And then from there, it's an iterative cycle. But this is a model that I really like just as a framework for thinking through things as it comes to especially that culture change more than just, hey, here's a new study. We're tweaking our sedation. But we as a culture are going to shift to a lighter sedation model. That takes a little more work and buy-in. Thanks, Erica. And you're right. It is a culture change. And if you don't deal with that culture or adaptive change that's needed, you won't be successful. So thanks a lot for that, Erica. Hey, Chris, what do you think are the most useful functional outcome tools to measure the mobility status of our patients in the ICUs? There are currently several skills and scores developed for specifically for the ICU. And there are some scores that are specific for physical therapy that are a lot more comprehensive. But what I would suggest is that whatever is chosen that all of the professionals feel comfortable using it. I think it's important to have an opportunity to discuss what the options are and for each ICU to determine what works best. The ICU mobility scale, that is a scale from 0 to 10, it's very easy because it's a mobility marker. And it was developed so that could have this interprofessional conversation about mobility. So for example, if they say the patient is an IMS 4, everybody knows that the patient is stood up. The doctor knows, the social worker knows, the RT knows, and all that. But when you read the definition, it's like the patient can stand up by himself or if you put a patient on the tool table, that's a 4. So for me as a physical therapist, it's very hard for me to use the IMS because the ability to detect change related to the physical therapy interventions is not, for me, not as good. But I think it's great as a mobility marker to determine what the patient did on every nursing shift or even like on that therapy session. There's also the SOMS that was mentioned over there, which I personally like a lot. It's because instead of 10, it's just five options. And it's very simple because it just goes from doing nothing to 4 that is walking. And for example, the good thing about that is that if nurses are using the SOMS, again, it's a mobility marker. So if the patient is a SOMS of 4 and the patient walked, it doesn't really matter if the patient walked 5 feet, 50 feet, or 500 feet. The only thing that really matters is the message that the patient walked. So if the patient is a SOMS of 4 for four days in a row, and then all of a sudden, for no medical reason, no surgery, no decline in the patient's condition, all of a sudden, the patient is a 2 for two days, I think there is a reason to try to understand what happened. Again, for me, the SOMS would not really be as a physical therapist as the best choice because I need to know how much, I mean, the distance that my patient walked and all that. So again, there are multiple options out there. But I think we have to really also understand that each different HICU is unique. And the staff has to really decide what works for them. So that way, we know that there is compliance with that. Well, thanks, Chris. And I know we've just adopted moving to the Johns Hopkins highest level of mobility scale, which is a 1 through 8 scale. And again, the purpose is so everyone on the team knows where they're at. You can trend if we're progressing or if we're declining. So I think there's lots of great tools. But the message here is to have one. Have one. Have one so that your team will know where this patient at on mobility. It can be discussed on rounds. Like you said, if I move back on that scale, OK, what's happening and what do I need to do different or if I'm not progressing. So thanks for sharing that, Chris. So Matt, question to you. What's your approach in ICU rounding to reinforce the implementation of the ICU liberation bundle? So it's an interesting question. I will say, so for a long time, UCSF, we told ourselves that we had nurse-led rounds. And we didn't. We had a protocol. We went to a lot of bedsides. And we started rounding when the nurse was in, giving a bed through the feeding tube. And so we've struggled with this. So I will say, certainly, I think in our current state, what is most effective with bundle implementation is truly having implementation nurse-led rounds. So and I would say across most of our ICUs, we've gotten to the point that rounds do not start until the nurse presents data. And so for us, that was how we had to do it. Until we turned over data presentation to the nurse, we would inevitably jump into rounds. And then we would be halfway through. And then we would be, and then the nurse would come out of the room. And then we'd be rushing. And we wouldn't get anywhere. And then inevitably, then it was all disjointed. And then we'd fail to cover various parts of the bundle and whether we were compliant on a given day. So for us, the big implementation, and I would say for anything, is truly nurse-led rounds. And there's some variety in what this means. And it can mean different things in different institutions. But fundamentally, it means the nurse is not just present, but is driving rounds. And I think when we've done that, we've been able to stay standardized in our approach. And we've been able to make sure that we're having discussions about bundle elements for every patient every day. So there are other approaches you can do. Certainly, checklists can have a role. We have had checklists on whiteboards. We've had checklists on paper. We've had checklists on an iPad. We've had checklists written on the glass doors, sometimes in permanent marker. And they never come down. We've had all sorts of checklists. But none of that, I will say, we have developed and discarded more checklists than I know what to do with. To me, fundamentally, having an understanding and buy-in from the bedside nurse and then having that nurse lead rounds each day has been the most important measure that we've implemented for bundle implementation. Thanks, Matt. And I agree that if you don't have the nurse there, or if that's a second thought, oh, any problems or concerns after you go through setting the goal for the day. So yeah, so having the nurse be an integral part where you're discussing each of the components of the bundle is one of the ways to truly get it implemented so that it's something every day discussed. So I'm going to ask Michelle, what are you finding that? So we have talked a little bit about how EMR integration with the bundle helps to reinforce. And it helps with workflow. It helps with bundle implementation. What's your experience at integrating ICU liberation into the EMR and its impact? So I'll piggyback a little bit onto what Matt said. So I'm in a unique role because my institution is actually, right now, going through our two-year process implementing EPIC. So I don't know if any of you have had the privilege and pleasure of going through that process recently. So what I had heard from my colleagues being part of the ICU Liberation Committee is that EPIC has this wonderful ICU liberation tool. And what I had heard is that, like Matt had said, it had been a challenge if you're an existing EPIC customer. It could be a challenge to get the documentation implemented. Because when you're already built and existing and you have your flow sheets and your documentation built, it can be hard to go back and get something added into your documentation. And certainly, I think we do have the slide, the QR code that we can put up. The QR code's at the end here. Yeah. And this can be helpful to bring to your informatics team. But what I wasn't anticipating as being part of a project that was a new build was that I was going to have the same challenge in having to advocate and push for this tool. And so as we began our journey and I was in meetings with the EPIC team and our partners, crickets. I heard ICU liberation, this ABCDEF bundle mentioned zero times. We had all these huge demos from the company. This was mentioned not once. And so I began to be the squeaky wheel and to ask about it and ask about it. And I'm so glad I did because it's a fantastic tool. And so I kept having to ask for the EPIC team to put demos together for my hospital leadership, for our nursing teams, for informatics. And my nursing partners didn't know this tool existed either. And they were thrilled because imagine the work it saved them to have to build this documentation for themselves. So that was something that I didn't expect. So you really do have to take ownership and find out what tools exist for the EPIC or the other EMRs and really not rely on the company partners to present these tools to you. Granted, as soon as I mentioned it, they had the knowledge to do this and they're being wonderful about it. They're well versed. But it was surprising, to say the least. Yeah, so it is a challenge. But it's worth the journey. 100% worth the journey. And the ability to see summary screens of when you're on rounds. And to be able to have, and especially for my respiratory therapist, to be able to have that. What's nice about this tool is that you have that information of, is my patient, did they pass their SAT safety screen? That data is going to flow in bidirectionally to everyone's flow sheets. The respiratory therapist will know. They'll know that they can go to their patients and do their SBT safety screens. And then everyone can share that documentation and that data. And it's in one place. And it's game changing. So we have about five minutes left. And we want to take questions from you. Either sharing what your challenges are, or successes. Or just any questions you might have for any of us on the panel. Thank you both. I'm Derek Collier from Nashville. I do full-time locum, so I go to different systems all over the country. I have a couple of questions. And I'm sorry, I forget your name. Erica? No, no, no. I'm John. I went to a talk a couple of days ago where we talked about the use of opioids for sedation. And you went through a whole talk on sedation and didn't mention a single opioid. And I'm thankful for it. Are we at a place where we should probably recommend against the fentanyl infusions? Because I get asked that a lot for sedation. I say, well, what do we need this highly potent synthetic opioid to do if the patient is not at an incision or a fracture? That's an interesting question. I mean, certainly in our practice, there's a fair amount of fentanyl drips depending on the patient. I don't think we're at the point we're going to recommend against opioids. And certainly, we went through a stage where we were very focused on inalgalicidation. And I find the term a little awkward, but basically very much an analgesic first approach. I think that our general practice is that we start with PRNs. And I do think that an early reliance on a drip sometimes is a mistake. But I will say, if you look at all the trials that looked at minimizing sedation, and certainly the non-SEDA trial, there's a lot of opioids. I mean, if you're not using sedation and you have an intubated patient, you're generally speaking using something. I mean, there may be a rare patient that you can keep calm with structured reassurance protocols, but most patients need something. And so it's either going to be a light dose of a continuous sedative, or it's going to be an opiate. And then I think the question becomes, do you convince yourself that you're not using sedatives in large doses, but you end up just using high doses of opioids, both in PRNs and drips? And I think you have to balance what the harms are with that. So I certainly think not going automatically to every patient to a drip makes sense. But certainly, we're using a fair amount of PRNs in our practice. OK, thank you. And treating pain first. Yeah, I mean, I think that's clearly. It's just that I think you just need to have an honest discussion with yourself and your team about whether you're using the opiate itself for sedation. And you've moved past treating pain and really monitoring the extent that you're effectively treating pain. Can we go to someone? Please, please do. So young lady in the back. Thank you. Peter, here locally in Scottsdale. And a suggestion and a question. So we, as well, have Epic. And we've developed a multidisciplinary rounding sheet. So our rounds are well nurse-driven, as well. But there's a structured document that covers everything in the bundle. And it actually is the information is pulled from Epic. So as the day shift nurse is giving this rounding, it's the data from the last 12 hours. It's the CAM assessment, the pain assessment, the drip status. And we've added other things in there, as well, such as Foley days and line days in an attempt to pull those out, as well. So a suggestion in case you have Epic. Question on immobility. As we know, it is not just for nurses or PTOT. There is a good portion of the nurses that struggle with the thought that they're going to hurt the patient. It's safer if I leave them in bed. Thoughts on how to turn that around? I'm sorry, can you just repeat it? Because it echoed, and I didn't hear it. Oh, sure. Thoughts on how to get the nurses to feel a little more comfortable mobilizing their vented patient with lines. There seems to be a concern that they're scared they're going to do more harm than good. Oh, and that's absolutely true. Because mobilizing a critically ill patient intubated with a lot of lines, it's not something that we are born knowing how to do it, you know? And obviously, the more you do it, the better you get at it. So, and also, I feel that a lot of nurses, they are not comfortable even knowing if the patient can stand up. So I think education is the key. So if you feel like a lot of the nurses are not certain about that, perhaps reaching out to the rehab department, to the physical therapy department, and request that our staff can come there and just teach the nurses. I certainly have done this over and over and over again. And sometimes, some simple strategies to teach the nurses before you get any patient out of bed, lift the leg up to see if they can manage to maintain the leg out of, you know, against the gravity. That already tells you if the patient can stand or not. And also, line management is a skill, and all of us working together, I think it does the job. So what I also would say is that start slow, you know? So we don't expect the nurses to get the patient into bed and walk, you know, around the ICU. But again, try sitting somebody on the side of the bed. You know, if they're doing very well, just try standing up. Sometimes the patient takes just a few steps at the bedside, it's all it takes. So please don't give up, you know? Just reach out to PTs and OTs to assist the nurses with whatever their needs are. So there's a nursing tool called the BMAT, the Bedside Mobility Assessment Tool, that can help make the nurse feel comfortable in what ability the patient might have. But I agree with Chris, you do need to get someone watching the respiratory, watching the ET tube, someone watching the line. So we'd say it's not an easy feat, but doable. Thank you. And I'll just add one thing as well from an onboarding perspective. And I know every new hire process is different, but usually there's some built-in time for multidisciplinary shadow experiences. And I always encourage my nurses to use that chunk of time to go with a skilled ICU physical therapist to get some of that hands-on piece, because mobility's not just a cognitive thing. You have to feel comfortable physically doing it. And I would also just say, make sure your preceptors are onboarding comfortable, because if they're doing it daily during orientation, that will help them feel comfortable to do it on their own. So we are five minutes past time. We are available for questions, but I want to thank you for being here today. And hopefully we were able to meet some of the objectives that you came into the room for, and have a great rest of Congress.

ICU Liberation

ABCDEF bundle

leadership buy-in

nurse-led rounds

cross-disciplinary approaches

EMR integration

patient outcomes