IMPROVING PATIENT CARE WITH THE ICU LIBERATION BUNDLE

Division Chiefpulmonary And Critical Care Medicine

WALTER KLEIN MD, FCCP, LESLEY ANNE BELLOWS

MARKETING, MEDIA AND COMMUNICATIONS

For several years, Riverside University Health System (RUHS) – Medical Center has been part of a national movement to work to reduce the incidence of delirium in the Intensive Care Unit (ICU), to support more positive outcomes for the patient. Known as the ICU Liberation Bundle (A-F), these methods were developed with the goal of guiding healthcare workers to ways that can limit, or eliminate delirium, which is common during hospitalization. There are three major subtypes of delirium: hyperactive, hypoactive, and the most common type, which is a mixed form of both hyperactive and hypoactive delirium. In a general sense, delirium is a disturbance of consciousness or acute change in cognition, as well as a reduced ability to focus or shift attention.

“What we know is that about 50 to 80% of all patients who are hospitalized in an ICU will develop some form of delirium. We also know that if a patient develops delirium, there’s a likelihood of increased mortality, upwards of 10%,” said Dr. Walter Klein, Division Chief of Pulmonary and Critical Care Medicine at Riverside University Health System. Dr. Klein noted that in prior years, common practice was to use various medications to treat delirium, such as antipsychotic medications or different sedatives, but none of these seemed to reverse delirium within the ICU. With that in mind, the best treatment appears to be prevention.

Dr. Klein is supportive of the ICU Liberation Bundle, stating that “a move towards this [bundle] is a huge step towards holistic, patient-centered care. We’re no longer treating a diagnosis; we’re treating the patient.” What is the ICU Liberation Bundle? In short, it’s a series of steps, labeled A through F, that correspond to individual elements that have shown to assist patients in avoiding de- lirium during their hospital visit.

• A Element: Assess, Prevent, and Manage Pain

• B Element: Both Spontaneous Awakening Trials (SATs) and Spontaneous Breathing Trials (SBTs)

• C Element: Choice of Analgesia and Sedation

• D Element: Delirium: Assess, Prevent, and Manage

• E Element: Early Mobility and Exercise

• F Element: Family Engagement and Empowerment

These six elements are implemented with a goal of controlling pain and minimizing sedation, both of which are clearly associated with an increased risk of developing delirium in the ICU. Additionally, the healthcare team will perform a paired spontaneous awakening, where the sedation is removed and a spontaneous breathing trial is done. When combined with mobilization and family engagement, these techniques have impressive results.

According to the Society of Critical Care Medicine’s (SCCM) website*, these changes can make a huge impact on the outcome of a patient’s visit to the ICU. “By fostering a holistic approach to treating patients and improving ICU team communication, the ICU Liberation Bundle has been proven in multiple studies involving more than 20,000 patients to:

• Decrease the likelihood of hospital death within seven days by 68%

• Reduce delirium and coma days by 25% to 50%

• Reduce physical restraint use by more than 60%

• Cut ICU readmissions in half

• Reduce discharges to nursing and rehabilitation facilities by 40%

At Riverside University Health System, the results have been positive, with multiple disciplines stepping in early in the patient’s care, even if the patient is on mechanical ventilation. Dr. Klein says that “we are getting physical therapy, occupational therapy and speech therapy involved, doing cognitive therapy and mobilizing patients early in their treatment.” The team approach is an exciting aspect, because everyone has the ability to participate in this bundle, from the physician team to the bedside nurses and therapists.

When Dr. Klein and the RUHS team began implementing this bundle in 2015, there was a lot of education and training, that is continuing today as they onboard new team members. Rolling out this program was a positive thing, overall. He noted that the arrival of the COVID-19 pandemic has provided some challenges for many reasons, one of which being the lack of engagement of family and friends, which has been limited by ongoing visitor restrictions. Additionally, the pan- demic has led to an influx of temporary healthcare workers (often referred to as ‘travelers’), so there’s a learning curve for those members of the team, and it also generates the need for constant training of new staff.

As the healthcare community continues to rebuild from the pandemic, the goal is to get engagement from across all disciplines to provide holistic treatments to every patient. “Ultimately, I feel that this is the reason why all of us went into medicine, to focus on patient-centered care,” said Dr. Klein, and he believes that this approach offers opportunity to positive interactions between different care teams, stating “I think this is something that will grow with time and allow for collaboration across disciplines, which is one of the most exciting things for me.”

*https://www.sccm.org/Clinical-Resources/ICULiberation-Home/ABCDEF-Bundles