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The ABCDEF Bundle
18 Plays6 years ago
In this episode, we discuss the ABCDEF bundle, a tool used to promote evidence-based care that promotes healing and liberation from critical illness for patients in the ICU. Our guest is Dr. Julia Barr who is currently the Associate Professor of Anesthesia in the Medical Center Line at Stanford Medical School and a staff anesthesiologist and intensivist at the VA Palo Alto Medical Center. Dr. Barr has served as a national faculty member for the SCCM ICU Liberation Campaign ABCDEF Bundle Collaborative and is a member of the SCCM’s ICU Liberation Committee.
Additional Resources:
Society of Critical Care Medicine’s guidelines on management of pain, agitation and delirium: http://www.sccm.org/Research/Guidelines/Guidelines/Pain,-Agitation,-and-Delirium-in-Adult-Patients-in
Society of Critical Care Medicine’s guidelines for Family-Centered Care in the ICU: http://www.sccm.org/Research/Guidelines/Guidelines/Family-Centered-Care-in-the-ICU
Books Mentioned in This Episode:
The Power of Habit: Why We Do What We Do in Life and Business: https://www.amazon.com/Power-Habit-What-Life-Business-ebook/dp/B0055PGUYU/ref=sr_1_2?ie=UTF8&qid=1530020419&sr=8-2&keywords=the+power+of+habit
Recommended
Transcript
Introduction to 'Critical Matters' Podcast
00:00:09
Speaker
Welcome to Critical Matters, a sound critical care podcast covering a broad range of topics related to the practice of intensive care medicine.
00:00:17
Speaker
And now, your host, Dr. Sergio Zanotti.
00:00:22
Speaker
The ABCDEF bundle is a tool used to promote the assessment, prevention, and integrated management of pain, agitation, and delirium, while also facilitating weaning from mechanical ventilation, maximizing early mobility, and involving families in the process of caring for critically ill patients.
What is the ABCDEF Bundle?
00:00:40
Speaker
It has been called the bundle of a lifetime in reference to the central role it plays to what we do in the ICU, and more importantly, to the goal of getting critically ill patients back on their feet, flourishing as human beings.
00:00:52
Speaker
It's a great pleasure to have as our guest today to discuss this very important topic, Dr. Juliana Barr.
00:00:59
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Dr. Barr is currently Associate Professor of Anesthesia in the Medical Center line at Stanford Medical School and a staff anesthesiologist and intensivist at the VA Palo Alto Medical Center.
00:01:10
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Dr. Barr is an accomplished academician with a large number of publications.
00:01:15
Speaker
She was the lead author in Society of Critical Care Medicine's 2013 Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium,
00:01:24
Speaker
in adult patients in the intensive care unit.
00:01:27
Speaker
Dr. Barr has also served as a national faculty member on the SECM ICU Liberation Campaign ABCDEF Bundle Collaborative, designed to promote widespread adoption of the guidelines and the ABCDEF bundles across more than 70 hospitals.
00:01:43
Speaker
And she currently is a member of the SECM's ICU Liberation Committee.
00:01:47
Speaker
She is a passionate advocate for improving the lives of critically ill patients and a true pleasure to have her on the podcast.
Explaining the Six Interventions
00:01:53
Speaker
Welcome to Critical Matters, Julie.
00:01:57
Speaker
Sergio, thank you for that warm introduction, and it's truly a pleasure and a privilege for me to be here today to speak with you and the audience about the ABCDEF bundle.
00:02:10
Speaker
Excellent.
00:02:11
Speaker
So recently we had the opportunity to do a webinar with Dr. Barr, which covers the why and many aspects of the how and the what of the ABCDF bundles.
00:02:21
Speaker
And that webinar will be linked in the show notes.
00:02:24
Speaker
Today's podcast is meant to be a compliment of
00:02:27
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and really explore some of the most common questions that have arisen from the efforts through the collaborative with more than 70 hospitals implementing the bundles.
00:02:37
Speaker
But I think, Julie, that maybe we should start by telling the audience what are the elements or defining the elements of the ABCDEF bundle.
00:02:48
Speaker
Right.
00:02:48
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So the ABCDEF bundle consists of six
00:02:55
Speaker
interventions, and each of the letters of the bundle refer to a major intervention.
00:03:04
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So A has to do with the assessment, prevention, and management of pain.
00:03:10
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B is a reminder to conduct both spontaneous awakening trials and spontaneous breathing trials together.
00:03:21
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C is the choice of sedation strategy.
00:03:25
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and sedation medications.
00:03:27
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D is for the assessment, prevention, and management of delirium.
00:03:33
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E is for the early mobility and exercise of patients.
00:03:37
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And F is for family engagement and empowerment.
00:03:42
Speaker
And I think that one of the important aspects of this that we'll also touch at the end of the podcast is
00:03:49
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is that none of this can happen without the collaboration of multiple disciplines in the ICU.
00:03:55
Speaker
So an element that's very important to the success of these bundles is the integration of a multi-professional team.
00:04:05
Speaker
Yes, I would agree.
Pain Assessment in ICU
00:04:07
Speaker
So why don't we start with A. And as you mentioned, Julie, A refers to assessing, preventing, and managing pain.
00:04:14
Speaker
And I think it's important as the first one, not only because it's utilized in the acronym, but also because probably when we have patients in the ICU and we have patients on mechanical ventilation, pain is often mismanaged and should be the first thing that we're addressing.
00:04:32
Speaker
So one of the questions that arose that is very common is,
00:04:37
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The guidelines recommend the use of objective criteria to assess pain.
00:04:42
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When our patients can communicate with us, they will use a numeric rating scale, the NRS scale, to give us a pain scale from zero to 10.
00:04:51
Speaker
However, many of our patients
00:04:53
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are not able to communicate, they're intubated, and might not be able to interact with us.
00:04:58
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And in those patients, we've assessed their pain through the critical care pain observation tool, the CPO2.
00:05:04
Speaker
How does these two tools or different ways of assessing pain compare or relate to each other?
00:05:09
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Are they the same in terms of that number eight means the same and the reaction should be the same?
00:05:15
Speaker
That's a really excellent question, and we hear that a lot.
00:05:19
Speaker
So it's important to recognize that we don't yet have a box that we can hook up to patients and detect pain, or for that matter, assess how much pain a patient is experiencing.
00:05:35
Speaker
So we're left with these subjective measurements, to your point, the numerical rating scale, which is a 1 to 10 scale for use in patients who can give a number to their pain intensity.
00:05:49
Speaker
and a behavioral pain scale of which the critical care pain observation tool or CPOT tool is one example of to assess pain in patients who cannot self-report.
00:06:03
Speaker
And as you pointed out, Sergio, many of our patients fall into that category.
00:06:08
Speaker
And I think that's been a gap in the care of our patients in most ICUs where behavioral pain scales have not been implemented.
00:06:17
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Now, I often
00:06:18
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hear people say, well, when we talk about pain severity using the numerical rating scale, we kind of divide that 1 to 10 scale up roughly into thirds, with 1 to 3 being mild pain, 4 to 6 being moderate pain, and 7 to 10 being severe pain.
00:06:40
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But a similar range of pain severity cannot be applied to the CPOT scale.
00:06:48
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there's, because it's a nonlinear scale.
00:06:51
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So think of the CPOT scale as a tool that merely detects the presence of significant pain that should be treated.
00:07:01
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And it's also not a one to 10 scale, it's a one to eight scale.
00:07:07
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And the CPOT score of
00:07:13
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three or higher is considered indicative of significant pain that should be treated.
00:07:20
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But you can't say with confidence that somebody who has a CPOT score of, say, seven is experiencing a greater degree of pain than somebody with a CPOT score of four.
00:07:36
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So CPOT is really a pain detection tool
00:07:39
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but it's not as granular as the numerical rating scale and cannot be used to assess severity of pain.
00:07:48
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So I think that that's a very important point.
00:07:50
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If you are able to do a numerical rating,
00:07:52
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rating scale, you can utilize that mild, moderate, or severe pain to direct your therapy in terms of using less or higher doses of analgesics.
00:08:03
Speaker
But in those patients who cannot communicate through the numeric scale and we use the CPOT, it's really only a dichotomy, either zero, no pain, or they have pain, and we have to treat
Prioritizing Pain Before Sedation
00:08:14
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as best we can.
00:08:14
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Is that correct?
00:08:16
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Yes.
00:08:18
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And I think it's also worth mentioning or reemphasizing, Julie, that probably the first assessment that we should always do is pain.
00:08:27
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And when somebody says the patient's uncomfortable, the patient's agitated, the patient is X, really we should first assess are they having pain with one of these two scales, right?
00:08:38
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Yes, we call that an analgo sedation or analgesia first strategy for patients.
00:08:46
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It's not an accident.
00:08:48
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that the first letter of the A through F bundle is related to optimizing pain management in patients because that's the first priority.
00:08:59
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And it's also important to recognize that all ICU patients at some point during their ICU stay will experience significant pain.
00:09:10
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We know that from the THUNDER-2 trial that Kathleen Pontillo and colleagues conducted and published several years ago.
00:09:18
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And pain is not limited to patients who have invasive devices in place or have had recent surgery.
00:09:27
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In fact, if you ask ICU survivors, significant pain is their most common memory of their ICU stay.
00:09:36
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And they will tell you, if you ask them what the sources of significant pain were that they experienced, it might surprise you to learn that
00:09:46
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It's not when somebody pokes them with something sharp, like to start an IV or put in a chest tube, but in fact, it's when they get turned in bed that's one of the most significant sources of pain in these patients.
00:10:03
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So it's really important to recognize that all patients are likely to experience significant pain in the ICU and that we should invariably assess pain first
00:10:13
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before reaching for a sedative medication to treat an agitated patient.
Eligibility for Spontaneous Breathing Trials
00:10:20
Speaker
Those are excellent points, and I think it's worth emphasizing because I often see that we tend to forget or not pay as much attention as we should to these issues.
00:10:30
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The second part of the bundle, or letter B, stands for both spontaneous awakening and breathing trials.
00:10:37
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And one of the questions that often gets presented either in the daily clinical care of patients or when programs are starting to implement these bundles is which patients are eligible for a spontaneous breathing trial.
00:10:53
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Could you expand on that, Julie?
00:10:57
Speaker
Yes, thank you, Sergio.
00:10:59
Speaker
First of all, let me just say the spontaneous awakening trial and spontaneous breathing trial are two interventions that were developed and tested separately, and both have been shown to shorten the duration of mechanical ventilation and to shorten ICU length of stay.
00:11:20
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However, the ABC trial, the awakening and breathing coordination trial,
00:11:25
Speaker
performed by and published by Tim Girard and colleagues at Vanderbilt a decade ago showed us that when you combine these two interventions and you incorporate appropriate safety screens before you conduct first the SAT and then the SBT trial, that you get greater synergistic improvements in terms of
00:11:54
Speaker
further reducing duration of mechanical ventilation, ICU length of stay, as well as outcomes, other clinical outcomes such as mortality and delirium.
00:12:06
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So it's important to pair these two interventions together.
00:12:11
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Now, having said that, it's also well documented that not all patients should have either an SAT or an SBT trial.
00:12:24
Speaker
But if a patient does pass their spontaneous awakening trial, which involves the discontinuation of sedative infusions or bolus dosing, as well as opioid infusions, which have both sedative effects and respiratory depressant effects, their criteria for undergoing an SBT trial takes into consideration a number of
00:12:53
Speaker
of respiratory parameters, including things like an FiO2 of 60% or less.
00:13:01
Speaker
Some people are even more conservative than that, using the FiO2 cutoff of less than 50%.
00:13:08
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A PaO2 to FiO2 ratio of greater than 150 to 200, and less than 8 centimeters of water of positive end-expiratory pressure.
00:13:22
Speaker
There are other non-respiratory screening criteria to be considered as well, such as whether or not a patient has had a recent MI within the last 24 hours, is having active seizures, is hemodynamically unstable on multiple vasopressors, or has increased intracranial pressures.
00:13:49
Speaker
those patients should probably also forego a spontaneous breathing trial.
00:13:56
Speaker
And I think that other things to mention might be aspects of the care of plan, patients that might be going for surgery or having other procedures.
00:14:05
Speaker
If you know you're not going to extubate them, it might not be the best time to do the SBT as
Sedation Strategies in Ventilated Patients
00:14:09
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well.
00:14:09
Speaker
Is that correct?
00:14:11
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Yes.
00:14:13
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So the C stands for the choice of analgesia and sedation.
00:14:17
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But the next question, I think, really applies to both the SPTs, SATs, but also how we deal with our analgesia and sedation afterwards.
00:14:26
Speaker
And the question, Julie, is in those patients who are mechanically ventilated, who undergo an SAT and do not pass the SPT, so will not be extubated, the question is,
00:14:37
Speaker
but they remain comfortable and without any agitation after their SAT and SPT, do we need to restart the IV sedative infusion, or how would you deal with the sedation at that point?
00:14:50
Speaker
You know, sedation is not a foregone conclusion in the management of every mechanically ventilated patient.
00:14:58
Speaker
There was a well-quoted study out of Denmark in 2010, I believe, that
00:15:06
Speaker
showed that you could safely manage patients using only pain medications that included opioids routinely and maintain patients in an awake, cooperative state without sedating them at all.
00:15:25
Speaker
Most ICUs, practically speaking, don't go to that extreme.
00:15:29
Speaker
There were also some other important limitations to that study.
00:15:33
Speaker
But I think it's important to recognize
00:15:36
Speaker
that it's not a given that every mechanically ventilated patient needs to be maintained in a drug-induced coma.
00:15:42
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In fact, that's associated with longer durations of mechanical ventilations and worse outcomes in those patients.
00:15:50
Speaker
So really, the ABCDEF bundle, in terms of defining whether sedation is needed or not, it's only if the patient is clearly anxious or otherwise agitated
00:16:05
Speaker
and pain control has been optimized.
00:16:10
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And there's another reason that they're agitated that might require sedation.
00:16:15
Speaker
Also, delirium is a common source of sedation.
00:16:19
Speaker
But what you really need to do is systematically assess patients for both significant pain and delirium before reaching for a sedative medication to manage their agitation.
00:16:30
Speaker
But if they're awake and calm,
00:16:34
Speaker
they may not need to go back on sedative.
00:16:36
Speaker
And if they can answer questions appropriately, they could probably tell you whether they would prefer to be on a sedative or not.
00:16:45
Speaker
But if a patient does need to be sedated, we recommend that a non-benzodazepine be used because benzos are associated with significant worse outcomes in these patients.
00:16:59
Speaker
which usually means that patients are sedated using either propofol or dexamethatomidine.
00:17:06
Speaker
And regardless of the sedative use, that you should target a light level of sedation that would correspond to a RAS scale of zero to minus two, which means the patient is either awake and calm or lightly sedated, but still able to follow the
00:17:27
Speaker
significantly follow simple commands.
Managing Delirium Non-Pharmacologically
00:17:31
Speaker
Absolutely.
00:17:31
Speaker
And I think that you mentioned delirium, which can take us into D, which stands for delirium, assess, prevent, and manage.
00:17:39
Speaker
And there's been a big emphasis in recognizing delirium in the ICU.
00:17:45
Speaker
A lot of ICUs, a lot of our listeners and their programs have
00:17:48
Speaker
have implemented different objective measures to try to identify these patients.
00:17:53
Speaker
One of the most common ones utilizes the confusion assessment method for the ICU or CAM-ICU.
00:17:58
Speaker
So the question, Julie, is what do we do on rounds when we recognize that a patient has a CAM-ICU that's positive?
00:18:06
Speaker
Great question, Sergio.
00:18:08
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So there's an overwhelming body of evidence that shows that patients
00:18:16
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ICU patients who develop delirium during their ICU stay have significantly worse outcomes, both in the short run and the long run.
00:18:28
Speaker
And there are a variety of what we collectively term as non-pharmacologic ICU delirium management strategies that help to both prevent and treat ICU delirium that
00:18:45
Speaker
each of these interventions taken separately have been shown to not only significantly reduce delirium prevalence in these patients, but generally these non-pharmacologic interventions are more effective than antipsychotic medications in treating these patients.
00:19:07
Speaker
So for instance, teloperidol, if you look at surveys of ICU providers,
00:19:14
Speaker
Haloperidol is the most commonly administered antipsychotic for the treatment of hyperactive delirium.
00:19:24
Speaker
And atypical antipsychotics are more commonly used to treat hypoactive delirium.
00:19:31
Speaker
Yet there's absolutely no evidence to show that haloperidol is effective at either preventing or treating ICU delirium in terms of
00:19:45
Speaker
of making a patient delirium-free.
00:19:49
Speaker
It may calm them down.
00:19:51
Speaker
They may stop being so agitated, but that doesn't necessarily translate to the absence of delirium because we know that the patients can also have hypoactive delirium, which is harder to detect.
00:20:05
Speaker
But even the evidence behind atypical antipsychotics
00:20:12
Speaker
is relatively weak.
00:20:13
Speaker
There's only a handful of small studies that have been published showing that those drugs are efficacious in the management of delirium regardless of whether they have hyperactive or hypoactive.
00:20:26
Speaker
Having said that, I think listeners should be aware that there's a very large multicenter trial that just finished about a year and a half ago called the MIND USA study, which
00:20:40
Speaker
looked at was a prospective randomized study that was blinded that looked at over 600 medical and surgical ICU patients who were diagnosed with delirium and they were treated with either haloperidol or zeprazidone which is an atypical antipsychotic or placebo again prospectively and in a blinded fashion for up to two weeks and
00:21:09
Speaker
The results of that study have not been published but are expected to come out later this year.
00:21:15
Speaker
And I think that this will help answer the question of the role of antipsychotics in the management of ICU delirium.
00:21:24
Speaker
Now, so what are the non-pharmacologic delirium management strategies?
00:21:29
Speaker
Well, I'd like to talk about the top 10 list.
00:21:34
Speaker
And item one would be optimal pain management.
00:21:38
Speaker
Two would be avoiding deep sedation because we know that both pain and deep sedation are independent risk factors for ICU delirium.
Importance of Early Mobility
00:21:47
Speaker
Three would be eliminating delirogenic medications.
00:21:51
Speaker
Four would be to remove invasive lines and tubes.
00:21:55
Speaker
Five is to avoid restraint.
00:21:58
Speaker
Six is actively and systematically reorienting patients.
00:22:04
Speaker
Seven is
00:22:08
Speaker
facilitating, promoting normal sleep-wake cycle, and eight is facilitating ventilator weaning, nine is mobilizing patients early, and ten is engaging ICU patients and families in care processes.
00:22:28
Speaker
And I think that, like you mentioned, Julie, it's very important to emphasize that since we don't have yet good data to tell us about effective treatments pharmacologically, that really we should be focusing our efforts in recognition and prevention at this point as much as we can.
00:22:49
Speaker
So one more question related to delirium.
00:22:53
Speaker
And I don't know if the collaborative looked at this, Julie, relates to when you measure CAMICUs on a regular basis in your ICU, as you implement this top 10 list, have people seen a decrease in the CAM positive days?
00:23:12
Speaker
So I would say that today nobody has put all 10 of these interventions together in a single comprehensive process.
00:23:23
Speaker
delirium management protocol and published the results of synergistically combining all of these things.
00:23:30
Speaker
But anecdotally, in the collaborative, when people focused on these strategies, that we saw a significant reduction in CAMICU positivity in patients in the collaborative.
00:23:49
Speaker
Excellent.
00:23:50
Speaker
So the next component of the
00:23:52
Speaker
bundle is E, which stands for early mobility and exercise.
00:23:57
Speaker
And I think that this is really a transformation of the way we care for these patients.
00:24:02
Speaker
When these patients decades ago were deeply sedated and immobilized for maybe weeks, now we see ICUs with very successful programs, getting people on the ventilator up and walking.
00:24:14
Speaker
But what I would like to ask you are two questions pertaining the early mobility, Julie.
00:24:19
Speaker
First,
00:24:21
Speaker
How do we make sure that all the efforts that we put in the ICU do not disappear once the patient leaves to the floor?
00:24:29
Speaker
So I think that sometimes I've seen a lot of effort to get people walking while they're in the ventilator, they get extubated, they finally leave the ICU, and then the physical therapy drops significantly at that point.
00:24:40
Speaker
Any comments from your experience at the VA or with the collaborative on this point?
00:24:47
Speaker
Yeah, that's a great question, Sergio.
00:24:49
Speaker
I know that several of the participating ICUs in the ICU Liberation Collaborative recognize this problem where they would have critically ill, mechanically ventilated patients doing laps around the unit on a daily basis.
00:25:06
Speaker
They'd get extubated and go out to the floor, and then they would lay in bed all day until they press the call light.
00:25:14
Speaker
for a nurse to come and help them go to the bathroom.
00:25:18
Speaker
And all the progress made on their truncal and leg strength in the ICU potentially could deteriorate.
00:25:29
Speaker
So I'll give you an example of one of our top performing hospitals.
00:25:34
Speaker
They took their mobility score that they had modified from the AACN
00:25:40
Speaker
mobility scoring system and extended that scoring system to reflect higher levels of activity in patients after they were transferred out of the ICU to the ward.
00:25:55
Speaker
And that way they were using the same mobility scales in the ICU and throughout the hospital.
00:26:02
Speaker
And that way everybody was speaking the same language and could more reliably track the progress
00:26:11
Speaker
or absence of their mobility progression during their entire hospital stay.
Timing and Type of Early Mobility
00:26:18
Speaker
It also enabled them to look at the effects of early mobility on getting patients back to their pre-ICU level of mobility and functionality, as well as tracking their
00:26:42
Speaker
skilled nursing facility discharge rates and correlating that with their mobility levels at the time of discharge.
00:26:50
Speaker
Yeah, and I think that the fragmentation of care is something that we see over and over again, but I think that it speaks to, as we implement these bundles, really integrate our teams that are outside of the ICU and making sure that our efforts continue, and that ultimately the real goal is to get the patient home, back and functioning as soon as possible.
00:27:10
Speaker
So we really need to continue our efforts throughout the hospital stay.
00:27:15
Speaker
The second question related to early mobility or to the E portion is, what do you consider the most useful outcome tools to measure mobility status in the ICU patients?
00:27:28
Speaker
Great question, Sergio.
00:27:30
Speaker
So, Trina, if you look at – let me back up a run.
00:27:35
Speaker
There was a recent worldwide ICU survey published by Morandi and colleagues
00:27:44
Speaker
which looked at sort of the current state of affairs of the A through F bundle in ICUs around the world.
00:27:57
Speaker
And what they found is that when it came to early mobility, although over 80% of the 1,400 respondents from 47 countries
00:28:13
Speaker
said they were doing early mobility in the ICU, what their definition of early mobility was did not meet criteria for what we think of as meaningful early mobility, which involves getting the patient upright under their own power with some assistance, and ideally marching in place or walking.
00:28:37
Speaker
So for the collaborative, our definition of
00:28:40
Speaker
early mobility was, at a minimum, was the patient could sit on the edge of the bed with minimal assistance.
00:28:48
Speaker
And then from there, they could progress to active transfer to a chair at the bedside, to standing and marching in place, to ambulating variable distances.
00:29:01
Speaker
So that's what we define as early mobility.
00:29:04
Speaker
In reality, most ICUs who claim to do early mobility, less than a third of them,
00:29:13
Speaker
target ambulation of their patients.
00:29:17
Speaker
And only about 20% of them use any sort of mobility scoring tool to assess the level of mobility and track that over time in patients.
00:29:29
Speaker
So most ICUs define their early mobility as either passive or active range of motion exercises in bed alone.
00:29:40
Speaker
which is better than nothing but clearly not enough to really get these patients out and functional again.
00:29:51
Speaker
Well, if you look at the studies of early mobility, it's a question of not only the type of mobility but the timing of it.
00:30:01
Speaker
So meeting patients where they are, not every patient is going to be able to get out of bed and walk around the ICU on their phone.
00:30:10
Speaker
first day.
00:30:11
Speaker
But if you make that their goal, number one, if that was their level of functioning prior to ICU admission, and number two, you start early mobility efforts within the first 36 to 48 hours of ICU admission, even in mechanically ventilated patients, that's related to much greater improvements in outcomes in terms of functional mobility
00:30:37
Speaker
at ICU and hospital discharge, it shortens ICU length of stay.
00:30:43
Speaker
And if you delay the onset of your mobility efforts, in one study they showed that waiting until they initiated early mobility a week after admission to the ICU, that there was no benefit, that there was no measurable difference in patients
00:31:03
Speaker
functionality or ICU length
Integrating Family in ICU Care
00:31:06
Speaker
of stay.
00:31:06
Speaker
So it's not only a question of how we define what early mobility really is, but the timing of it as well.
00:31:15
Speaker
Excellent.
00:31:15
Speaker
And I think that the take-home message also is similar to how we're approaching delirium, analgesia, and sedation, is to have objective measures that can tell us where that patient is and that can help us set goals.
00:31:29
Speaker
So the last component, Julie, of the bundles, the F stands for Family Engagement and Empowerment.
00:31:34
Speaker
And I think a very, very important aspect that perhaps earlier in the ICU days was somewhat neglected.
00:31:43
Speaker
And now I think that we really have embraced in many ICUs and really making sure that not only our families are engaged, but they're also empowered to participate and contribute.
00:31:54
Speaker
to the well-being or improvement of their loved ones.
00:31:58
Speaker
Could you tell us first what are some of the first steps that people can do in terms of making sure that families are engaged and empowered in the ICU?
00:32:11
Speaker
Well, I think, and this is not just my own preference or bias here, Sergio, but
00:32:20
Speaker
This comes from the recently published guidelines for family-centered care in the ICU that was published by a team led by Judy Davidson and Randy Curtis in 2017.
00:32:36
Speaker
And that updated version of the patient and family support guidelines, as we refer to them, outlined 23 different evidence-based strategies for improving and integrating family presence,
00:32:50
Speaker
communication and involvement in ICU patient care.
00:32:54
Speaker
Now, certainly these 23 recommendations include common ways to improve family engagement and access to their loved ones, such as 24-hour visitation, and having regular family meetings where providers sit with families and update them on
00:33:20
Speaker
status of patients and ask them if they have any questions, but it certainly doesn't stop there.
00:33:25
Speaker
And I think that the most important take-home point from these guidelines, the Patient and Family Support Guidelines, is that you have to start with the premise that the patient and their loved ones are actually a member of the care team.
00:33:43
Speaker
And we need to leverage
00:33:47
Speaker
what they bring to that interprofessional team-based approach that's patient-centered in the ICU.
00:33:57
Speaker
Because patients and families are the ones who can inform us about what their preferences and goals are for their care in the ICU and beyond, understanding
00:34:14
Speaker
what it is that we're all aiming for is extremely important and not presupposing that we can read patients' and families' minds and know what's in their best interest.
00:34:26
Speaker
So I think starting from that premise is very important.
00:34:30
Speaker
But in terms of defining the penultimate way to engage ICU patients and families, out of these 23 recommendations,
00:34:43
Speaker
the most important, I think, and this was the last take-home lesson from the ICU Liberation Collaborative, is actively involving ICU patients and families in ICU rounds.
00:34:59
Speaker
So what does that look like?
00:35:00
Speaker
Well, first of all, you have to have ICU rounds that happen at the bedside every day.
00:35:07
Speaker
And this is an interprofessional model that should include both
00:35:13
Speaker
the primary ICU provider that may be an intensivist, it may be a hospitalist, it may be the attending physician of record from a primary team in an open ICU model.
00:35:26
Speaker
But it needs to include the primary provider that is the decision maker and the order writer for that patient.
00:35:36
Speaker
But it should also include other members of the team, so the bedside nurse,
00:35:41
Speaker
a pharmacist and a respiratory therapist, that would be a minimum, but why stop there?
00:35:48
Speaker
You could have dieticians, social workers, physical therapists, palliative care team members.
00:35:56
Speaker
So don't limit your vision for the provider membership on that interprofessional team, but also including families and patients in those discussions.
00:36:08
Speaker
So you need to have those rounds
00:36:11
Speaker
happen at the bedside, not outside the patient's room with the door closed, but actually at the bedside.
00:36:18
Speaker
And that involves going in the patient's room and including them in the discussions.
00:36:22
Speaker
And I think in the ICU Liberation Collaborative, where ICUs embraced that model of interprofessional team rounds that included patients and families, they found that it did not impact the duration of rounds, which I think is a concern people have.
00:36:42
Speaker
And it actually increased trust between patients, families, and providers about their care and actually reduced the amount of time that providers spent outside of ICU rounds meeting and talking with patients and families about their care plan.
00:37:00
Speaker
So it's a win-win-win for all parties involved to include patients and families in ICU rounds.
00:37:08
Speaker
And I certainly think that that is a well-received change that we're seeing.
00:37:13
Speaker
I mean, there's still a lot of room for improvement, but the fact that we would have limited visiting hours and we would ask everybody to leave during rounds back in the days when I was training in my early practices and now to having families be part of the team and really being the experts on the human being who's being treated.
00:37:33
Speaker
I think is very, very refreshing, but also I think makes a big difference for the care.
Role of Diverse ICU Team Members
00:37:38
Speaker
And like you said, it's a win-win-win for everybody.
00:37:41
Speaker
So how should we measure the level of family engagement?
00:37:46
Speaker
Well, that's a very important question.
00:37:48
Speaker
So when we started the ICU Liberation Collaborative, the updated version of the patient and family center guidelines hadn't been published yet.
00:37:59
Speaker
And they came out kind of late in the collaborative process.
00:38:01
Speaker
And so we really struggled to define not only what the best practices were for patient and family engagement in the ICU in the context of the collaborative, but how to measure that.
00:38:15
Speaker
But once the guidelines came out, that really gave us a very clear roadmap of how to proceed.
00:38:24
Speaker
There's 23 options in there, and it can be a little overwhelming, kind of like sitting down to a five-pound box of cheese candy and not knowing where to begin.
00:38:32
Speaker
But actually, there's a really important tool.
00:38:38
Speaker
It's an interactive spreadsheet that's embedded in the published guidelines.
00:38:43
Speaker
It's also available for free on the ICU Liberation website through the Society of Critical Care Medicine.
00:38:51
Speaker
And it's basically a gap analysis tool to inform each ICU what their unique top three priorities should be to improve ICU patient and family engagement in their unit.
00:39:06
Speaker
So for some units who are already doing interprofessional team rounds successfully, they might look to additional options to further improve patient and family engagement, like implementing ICU diaries.
00:39:21
Speaker
or implementing not telehealth, but the use of tablets or smartphones at the bedside to include family members who can't be there for ICU rounds, but otherwise wish to actively participate in those discussions when they too do take place.
00:39:47
Speaker
So I strongly encourage people listening to the podcast to look at those patient and family support guidelines from the Society of Critical Care Medicine and make use of that gap analysis tool to find out what they can do in their units that's going to give them the biggest bang for the buck in improving patient and family engagement.
00:40:06
Speaker
In terms of how you measure that, there's a variety of ways to do that.
00:40:10
Speaker
You can do patient and family satisfaction surveys.
00:40:16
Speaker
objectively measure how many times during the day or week or month patients and families actively participated in round discussions.
00:40:28
Speaker
And again, those guidelines give you some metrics to look to.
00:40:33
Speaker
And I think that that's a great suggestion.
00:40:36
Speaker
And for our listeners, we will have a link in the show notes to the family guidelines from the SECM in addition to other resources.
00:40:46
Speaker
You had alluded a little bit earlier in the discussion to some of the components or some of the members of this interprofessional team.
00:40:54
Speaker
And as we all know, critical care, but especially the implementation of these ABCDF bundles is really a team sport.
00:41:02
Speaker
Could you talk a little bit on the specific roles of different members of the interprofessional team and making sure that the bundles are successful and that we're compliant with them?
00:41:15
Speaker
Yes, so first of all, as I mentioned earlier, you want to make sure that the right people are present for rounds.
00:41:25
Speaker
If you just have a physician and a bedside nurse doing, as we used to say when I went through my training, rocket rounds at oh dark 30 in the morning in the name of efficiency, and then all the other members of the team
00:41:42
Speaker
such as the respiratory therapist, pharmacist, dietician, physical therapist, etc., come around later and play guess what the physician was thinking if their area of expertise was not directly addressed during that conversation between the physician and nurse.
00:42:03
Speaker
That wastes a lot of time on all sides because now those
00:42:09
Speaker
ancillary providers have to go track down the physician, page them, go physically find them, and ask them what the goals are for their sedation that day, how to optimize their pain management, what have you.
00:42:23
Speaker
So it's really important to make sure that the right people are on rounds.
00:42:27
Speaker
And the SCCM is currently in the process of writing a white paper on defining
00:42:36
Speaker
who should be on those rounds.
00:42:38
Speaker
But as I mentioned earlier, the core team members as it pertains to the bundle should be a physician, a nurse, a pharmacist, and a respiratory therapist at a minimum.
00:42:52
Speaker
And then on rounds, it's important to give everybody a voice to make sure that all the bundle elements are actually addressed.
00:43:01
Speaker
So the recommended format for interprofessional team rounds
00:43:05
Speaker
is to provide a bundle-oriented script that the bedside nurse reads early on in the patient presentation that addresses all the bundle elements.
00:43:17
Speaker
And in our ICU, we use a similar type of script, and the nurse can check off all the bundle elements very quickly and efficiently in less than one minute.
00:43:27
Speaker
But that ensures that all the bundle elements are discussed on ICU rounds.
00:43:34
Speaker
Also,
00:43:36
Speaker
making sure that other members of the team are allowed to voice their opinions so that the physician really becomes the facilitator of a group discussion to, if you will, crowdsource the collective expertise of all team members as it pertains not only to the bundle but all aspects of care.
00:43:59
Speaker
So really flattening that hierarchy is key and that requires
00:44:04
Speaker
a culture of mutual respect and effective interpersonal communication amongst team members.
00:44:15
Speaker
Absolutely.
00:44:15
Speaker
And I think that, as we mentioned, the team is key in being successful in caring for these very complex, critically ill patients, not only in implementing the bundles, but in caring for them in the best possible way.
00:44:28
Speaker
And I think that
00:44:30
Speaker
Two of the fundamental factors or elements for success are a common sense of purpose in terms of really recognizing what we're trying to achieve, which is get that critically ill patient back on their feet, back to their life, and to be able to flourish and have a productive
Transformative Approach of the ABCDEF Bundle
00:44:49
Speaker
life with their family.
00:44:50
Speaker
But also, I think the second element, I think is very important, is recognizing the value of
00:44:56
Speaker
of each one of our members in the team and what they bring to the table as we implement these bundles.
00:45:02
Speaker
Are there any suggestions you could give us, Julie, in terms of how we can recognize ICU team members for supporting the ABCDF bundle efforts?
00:45:13
Speaker
I think that meaningful recognition is an extremely important tool to both accelerate bundle adoption and to sustain bundle adherence.
00:45:26
Speaker
But what do we mean when we talk about meaningful recognition?
00:45:32
Speaker
You know, that's kind of a vague term.
00:45:35
Speaker
But it's important to make it a public acknowledgement of a staff or a group of staff who have made a significant and concerted effort towards incorporating the bundle into their everyday practice.
00:45:53
Speaker
and also to give recognition in a way that is meaningful to them.
00:45:59
Speaker
So for nurses, very often it's about being mindful of ensuring that patients are comfortable and are happy with the care that they're receiving and that they feel included in the care processes.
00:46:21
Speaker
So having the meaningful recognition resonate with your frontline staff, you have to know what they value, what's important to them.
00:46:32
Speaker
But I also think that it's about recognizing not just individuals, but teams to make this happen.
00:46:40
Speaker
Because the A through F bundle is not a nursing bundle.
00:46:44
Speaker
I think that's a common mistake that people often make is they think, oh yeah, we're going to implement this straight bundle in our unit.
00:46:51
Speaker
and they're sitting who's going to lead the charge.
00:46:54
Speaker
Well, that's a recipe for failure.
00:46:56
Speaker
You really need to take an interprofessional team-based approach to actually implementing the bundle using continuous quality improvement techniques.
00:47:07
Speaker
And then you have to recognize and celebrate successes of the entire team.
00:47:13
Speaker
And the way you do that is by sharing data and setting goals and showing people where they're going and celebrating
00:47:21
Speaker
when you've made significant progress or ultimately achieved those goals.
00:47:26
Speaker
And that meaningful recognition shouldn't come just from local ICU leadership.
00:47:31
Speaker
It really needs to come from the C-suite to be most impactful.
00:47:38
Speaker
And that way, people know that the care that they're delivering to patients in the unit using the bundle is important to the entire institution.
00:47:49
Speaker
And I think that the other point that I often think about is that the implementation of these bundles is not a destination.
00:47:59
Speaker
It's really a journey.
00:48:00
Speaker
And that it's not like, oh, we already did that.
00:48:02
Speaker
There's always room for improvement as new data comes refining, because ultimately the goal is really to get these patients back on their feet as soon as possible and as strong as possible so they can resume their lives after a critical illness.
00:48:16
Speaker
Any comments on that respect, Julie?
00:48:20
Speaker
Yes, and I think I would add to that by saying that this bundle is fundamentally different than every other bundle that's ever been created to be implemented in an intensive care unit.
00:48:36
Speaker
And the most, if you think about other bundles like the sepsis bundle or device-related bundles like the CLABSI bundle, those only apply to a subset of our patients.
00:48:49
Speaker
Whereas the A through F bundle applies to every ICU patient every single day.
00:48:55
Speaker
And to implement the bundle really requires that we transform the way that we deliver care and the goals of that care in our ICUs.
00:49:10
Speaker
If you look at the goals of ICU care
00:49:14
Speaker
that you and I were raised with Sergio as junior intensivists, we kept everybody who was really sick on a ventilator in a drug-induced coma using a pharmacologic potpourri, if you will, of opioids, sedatives, and antipsychotics to maintain them in a deep sedation until they got better.
00:49:38
Speaker
And we didn't make any movement on the ventilation front.
00:49:44
Speaker
until their lungs looked like they were ready to be weaned and extubated from the ventilator.
00:49:52
Speaker
And we kept them in bed because we thought getting six patients out of bed was bad for them.
00:49:58
Speaker
And we limited family access to our patients.
00:50:01
Speaker
Basically, it was a passive approach to caring for patients, waiting for them to heal themselves, whereas
00:50:10
Speaker
The A through F bundle takes a much more proactive approach in optimizing pain management, avoiding deep sedation, minimizing delirium risk factors, recognizing and treating delirium using non-pharmacologic strategies, actively assessing and weaning patients for mechanical ventilation every single day, getting ICU patients out of bed,
00:50:38
Speaker
within the first day or two of admission to the ICU whenever feasible, and actively engaging ICU patients and families, all with the overarching goal of really helping patients to heal.
00:50:52
Speaker
But this requires careful interprofessional collaboration, communication, and care coordination, first and foremost, that doesn't begin and end with interprofessional rounds at the bedside.
00:51:07
Speaker
And that requires everybody to see themselves as part of the same team.
00:51:11
Speaker
It also requires that you have enough staff to pull this off and that you structure your ICU work environment around implementing the bundle on every patient every day.
00:51:25
Speaker
That you use real-time continuous quality improvement, not we did that last year, we've moved on to a new bundle this year.
00:51:34
Speaker
and data-driven performance assessment, all that is implemented in an ICU that emphasizes the importance of safety, culture, and respect for our coworkers and puts the patients and their families in the middle of our care plan, and that has strong leadership engagement from both within the ICU and from the executive suite at the hospital.
00:52:02
Speaker
That's the recipe.
00:52:03
Speaker
for success in successful implementation of the bundle.
00:52:07
Speaker
But once you
Personal Reflections and Episode Conclusion
00:52:08
Speaker
make that transformation in terms of how you deliver care in the ICU, you won't want to go back.
00:52:16
Speaker
There was a three-month period of time when I was on administrative leave from the ICU in my own unit.
00:52:24
Speaker
And in the meantime, we kept implementing the bundle.
00:52:26
Speaker
And after three short months, I came back to an ICU I didn't recognize, but for the better.
00:52:33
Speaker
And I remember thinking that first day I was trying to conduct interprofessional team rounds at the bedsides of patients.
00:52:39
Speaker
And I would go to a patient's bed and he wouldn't be there because he was out walking around on a ventilator.
00:52:45
Speaker
And then I had to keep stopping rounds to move out of the way because sick people that I thought I would never see out of bed were going to run me over with their walkers.
00:52:57
Speaker
So I think once you see that, it's really
00:53:02
Speaker
transformative in terms of how you view the work that you're doing in your ICU.
00:53:08
Speaker
Absolutely.
00:53:09
Speaker
And I think that, Julie, this has been a fascinating conversation on a very, very important topic.
00:53:15
Speaker
And I think, like you mentioned, it's something that applies to all the patients we see in the ICU.
00:53:21
Speaker
It's about getting every single patient that we treat better as soon as possible and delivering really a much more humane
00:53:30
Speaker
care in an environment that really empowers all the team members to be their best.
00:53:35
Speaker
And I think that we'll have probably more conversations about this topic.
00:53:39
Speaker
But as a closing, we traditionally will ask our guests some questions that are not directly related to the topic, but I think are related to life in general, and we think are important as aspects of our care as physicians, as intensivists.
00:53:56
Speaker
Would that be okay?
00:54:00
Speaker
So the first question is, what book or books have influenced you the most or what book have you gifted most often to others?
00:54:09
Speaker
My personal favorite is The Power of Habit by Charles Duhigg.
00:54:13
Speaker
And he talks about what drives our habits in our daily lives, both personally and professionally.
00:54:21
Speaker
And every habit has a cue, a routine, and a reward.
00:54:28
Speaker
And the way I think about
00:54:29
Speaker
restructuring habits in the ICU using the ABCDEF bundle.
00:54:34
Speaker
In the past, the cue has been, oh, this is a really sick patient.
00:54:39
Speaker
The routine has been, we need to keep him in a drug-induced coma until he's better.
00:54:45
Speaker
And the reward is whatever condition the patient emerged from at the other end of their illness.
00:54:53
Speaker
As long as they survive, that was our reward in the ICU.
00:54:58
Speaker
And now I think the A through F bundle forces us to think differently about those habits that we created that are so deeply embedded in our ICU culture.
00:55:09
Speaker
If you think that the cue is, okay, here's a sick patient, and the routine is, how do I optimize their pain management, avoid sedating them, and mitigate their delirium risk so that I can wean them off the ventilator faster and get them out of bed sooner?
00:55:27
Speaker
then the reward is not only a patient who survives their ICU stay, but has a much higher chance of returning to their life that they had before they became an ICU patient.
00:55:41
Speaker
Absolutely.
00:55:42
Speaker
And I think that it also speaks to the truth that much of what we're trying to do in transforming medicine is really about transforming behavior.
00:55:51
Speaker
And that we always focus on the latest evidence, but at the end of the day, it's creating these habits of excellent care over and over again that really make a difference for our patients.
00:56:04
Speaker
The second question, Julie, is what do you believe to be true in medicine or in life that most other people don't believe?
00:56:14
Speaker
You know, I take my inspiration from two people in particular, the first of which is the Dalai Lama, who said that nothing is permanent and change is inevitable.
00:56:25
Speaker
And I think that people who embrace change have a more impactful life.
00:56:34
Speaker
on their fellow human beings.
00:56:36
Speaker
And that's really about what implementing the bundle really means to me.
00:56:41
Speaker
It's about changing the lives of ICU patients that I will never meet.
00:56:47
Speaker
But I know that every ICU that implements the bundle, even imperfectly, is making a difference in the care and outcomes of their patients.
00:56:58
Speaker
And that's very important to me personally and professionally.
00:57:01
Speaker
The second person that I often quote is Maya Angelou, who said once that, people won't remember what you said, people won't remember what you did, but people will remember how you made them feel.
00:57:16
Speaker
And when I think of our patients and their family members in the ICU, that has become my mantra, is that how do our patients and family members feel
00:57:27
Speaker
about the care that we're delivering to their loved ones and how we include them in those care processes in the ICU.
00:57:37
Speaker
I think there are two very excellent points and phenomenal people to look up to and I think a lot to learn from in terms of how we can really be more compassionate when we're caring for critically ill patients.
00:57:49
Speaker
The final question just relates to what would you want every intensivist who listens to this podcast to know?
00:58:00
Speaker
You know, people believe in the A through F bundle for different reasons, but it's really not just about improving the efficiency of care and getting people out of the ICU and spending less money to do that.
00:58:16
Speaker
Certainly those gains will be realized.
00:58:20
Speaker
even with partial bundle implementation in your unit.
00:58:24
Speaker
But it's really about transforming the way we deliver care so that our ICU patients can not only survive but thrive and go back to leading happy lives after an acute life-threatening illness or injury.
00:58:47
Speaker
And I think that that's a great place to end.
00:58:51
Speaker
I really want to thank you, Julie, for your time, for sharing your knowledge with us.
00:58:57
Speaker
You're passionate about improving lives of critically ill patients.
00:59:00
Speaker
And I think a lot of our listeners hopefully will be inspired and be pushing for these bundles at their ICUs.
00:59:07
Speaker
And we hope to have you back soon.
00:59:10
Speaker
Thank you very much, Sergio.
00:59:12
Speaker
I appreciate the opportunity.
00:59:17
Speaker
Thanks again for listening to Critical Matters.
00:59:19
Speaker
Make sure to subscribe to this podcast on iTunes or Google Play.