Transcript
Speaker: Welcome to Critical Matters, a sound critical care podcast covering a broad range of topics related to the practice of intensive care medicine.
Speaker: And now, your host, Dr. Sergio Zanotti.
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.
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.
Speaker: It's a great pleasure to have as our guest today to discuss this very important topic, Dr. Juliana Barr.
Speaker: 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.
Speaker: Dr. Barr is an accomplished academician with a large number of publications.
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,
Speaker: in adult patients in the intensive care unit.
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.
Speaker: And she currently is a member of the SECM's ICU Liberation Committee.
Speaker: She is a passionate advocate for improving the lives of critically ill patients and a true pleasure to have her on the podcast.
Speaker: Welcome to Critical Matters, Julie.
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.
Speaker: Excellent.
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.
Speaker: And that webinar will be linked in the show notes.
Speaker: Today's podcast is meant to be a compliment of
Speaker: 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.
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.
Speaker: Right.
Speaker: So the ABCDEF bundle consists of six
Speaker: interventions, and each of the letters of the bundle refer to a major intervention.
Speaker: So A has to do with the assessment, prevention, and management of pain.
Speaker: B is a reminder to conduct both spontaneous awakening trials and spontaneous breathing trials together.
Speaker: C is the choice of sedation strategy.
Speaker: and sedation medications.
Speaker: D is for the assessment, prevention, and management of delirium.
Speaker: E is for the early mobility and exercise of patients.
Speaker: And F is for family engagement and empowerment.
Speaker: And I think that one of the important aspects of this that we'll also touch at the end of the podcast is
Speaker: is that none of this can happen without the collaboration of multiple disciplines in the ICU.
Speaker: So an element that's very important to the success of these bundles is the integration of a multi-professional team.
Speaker: Yes, I would agree.
Speaker: So why don't we start with A. And as you mentioned, Julie, A refers to assessing, preventing, and managing pain.
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.
Speaker: So one of the questions that arose that is very common is,
Speaker: The guidelines recommend the use of objective criteria to assess pain.
Speaker: 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.
Speaker: However, many of our patients
Speaker: are not able to communicate, they're intubated, and might not be able to interact with us.
Speaker: And in those patients, we've assessed their pain through the critical care pain observation tool, the CPO2.
Speaker: How does these two tools or different ways of assessing pain compare or relate to each other?
Speaker: Are they the same in terms of that number eight means the same and the reaction should be the same?
Speaker: That's a really excellent question, and we hear that a lot.
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.
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.
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.
Speaker: And as you pointed out, Sergio, many of our patients fall into that category.
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.
Speaker: Now, I often
Speaker: 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.
Speaker: But a similar range of pain severity cannot be applied to the CPOT scale.
Speaker: there's, because it's a nonlinear scale.
Speaker: So think of the CPOT scale as a tool that merely detects the presence of significant pain that should be treated.
Speaker: And it's also not a one to 10 scale, it's a one to eight scale.
Speaker: And the CPOT score of
Speaker: three or higher is considered indicative of significant pain that should be treated.
Speaker: 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.
Speaker: So CPOT is really a pain detection tool
Speaker: but it's not as granular as the numerical rating scale and cannot be used to assess severity of pain.
Speaker: So I think that that's a very important point.
Speaker: If you are able to do a numerical rating,
Speaker: 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.
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 as best we can.
Speaker: Is that correct?
Speaker: Yes.
Speaker: And I think it's also worth mentioning or reemphasizing, Julie, that probably the first assessment that we should always do is pain.
Speaker: 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?
Speaker: Yes, we call that an analgo sedation or analgesia first strategy for patients.
Speaker: It's not an accident.
Speaker: that the first letter of the A through F bundle is related to optimizing pain management in patients because that's the first priority.
Speaker: And it's also important to recognize that all ICU patients at some point during their ICU stay will experience significant pain.
Speaker: We know that from the THUNDER-2 trial that Kathleen Pontillo and colleagues conducted and published several years ago.
Speaker: And pain is not limited to patients who have invasive devices in place or have had recent surgery.
Speaker: In fact, if you ask ICU survivors, significant pain is their most common memory of their ICU stay.
Speaker: 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
Speaker: 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.
Speaker: 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
Speaker: before reaching for a sedative medication to treat an agitated patient.
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.
Speaker: The second part of the bundle, or letter B, stands for both spontaneous awakening and breathing trials.
Speaker: 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.
Speaker: Could you expand on that, Julie?
Speaker: Yes, thank you, Sergio.
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.
Speaker: However, the ABC trial, the awakening and breathing coordination trial,
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
Speaker: further reducing duration of mechanical ventilation, ICU length of stay, as well as outcomes, other clinical outcomes such as mortality and delirium.
Speaker: So it's important to pair these two interventions together.
Speaker: Now, having said that, it's also well documented that not all patients should have either an SAT or an SBT trial.
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
Speaker: of respiratory parameters, including things like an FiO2 of 60% or less.
Speaker: Some people are even more conservative than that, using the FiO2 cutoff of less than 50%.
Speaker: A PaO2 to FiO2 ratio of greater than 150 to 200, and less than 8 centimeters of water of positive end-expiratory pressure.
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.
Speaker: those patients should probably also forego a spontaneous breathing trial.
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.
Speaker: If you know you're not going to extubate them, it might not be the best time to do the SBT as well.
Speaker: Is that correct?
Speaker: Yes.
Speaker: So the C stands for the choice of analgesia and sedation.
Speaker: But the next question, I think, really applies to both the SPTs, SATs, but also how we deal with our analgesia and sedation afterwards.
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,
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?
Speaker: You know, sedation is not a foregone conclusion in the management of every mechanically ventilated patient.
Speaker: There was a well-quoted study out of Denmark in 2010, I believe, that
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.
Speaker: Most ICUs, practically speaking, don't go to that extreme.
Speaker: There were also some other important limitations to that study.
Speaker: But I think it's important to recognize
Speaker: that it's not a given that every mechanically ventilated patient needs to be maintained in a drug-induced coma.
Speaker: In fact, that's associated with longer durations of mechanical ventilations and worse outcomes in those patients.
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
Speaker: and pain control has been optimized.
Speaker: And there's another reason that they're agitated that might require sedation.
Speaker: Also, delirium is a common source of sedation.
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.
Speaker: But if they're awake and calm,
Speaker: they may not need to go back on sedative.
Speaker: And if they can answer questions appropriately, they could probably tell you whether they would prefer to be on a sedative or not.
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.
Speaker: which usually means that patients are sedated using either propofol or dexamethatomidine.
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
Speaker: significantly follow simple commands.
Speaker: Absolutely.
Speaker: And I think that you mentioned delirium, which can take us into D, which stands for delirium, assess, prevent, and manage.
Speaker: And there's been a big emphasis in recognizing delirium in the ICU.
Speaker: A lot of ICUs, a lot of our listeners and their programs have
Speaker: have implemented different objective measures to try to identify these patients.
Speaker: One of the most common ones utilizes the confusion assessment method for the ICU or CAM-ICU.
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?
Speaker: Great question, Sergio.
Speaker: So there's an overwhelming body of evidence that shows that patients
Speaker: ICU patients who develop delirium during their ICU stay have significantly worse outcomes, both in the short run and the long run.
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
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.
Speaker: So for instance, teloperidol, if you look at surveys of ICU providers,
Speaker: Haloperidol is the most commonly administered antipsychotic for the treatment of hyperactive delirium.
Speaker: And atypical antipsychotics are more commonly used to treat hypoactive delirium.
Speaker: Yet there's absolutely no evidence to show that haloperidol is effective at either preventing or treating ICU delirium in terms of
Speaker: of making a patient delirium-free.
Speaker: It may calm them down.
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.
Speaker: But even the evidence behind atypical antipsychotics
Speaker: is relatively weak.
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.
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
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
Speaker: The results of that study have not been published but are expected to come out later this year.
Speaker: And I think that this will help answer the question of the role of antipsychotics in the management of ICU delirium.
Speaker: Now, so what are the non-pharmacologic delirium management strategies?
Speaker: Well, I'd like to talk about the top 10 list.
Speaker: And item one would be optimal pain management.
Speaker: Two would be avoiding deep sedation because we know that both pain and deep sedation are independent risk factors for ICU delirium.
Speaker: Three would be eliminating delirogenic medications.
Speaker: Four would be to remove invasive lines and tubes.
Speaker: Five is to avoid restraint.
Speaker: Six is actively and systematically reorienting patients.
Speaker: Seven is
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.
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.
Speaker: So one more question related to delirium.
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?
Speaker: So I would say that today nobody has put all 10 of these interventions together in a single comprehensive process.
Speaker: delirium management protocol and published the results of synergistically combining all of these things.
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.
Speaker: Excellent.
Speaker: So the next component of the
Speaker: bundle is E, which stands for early mobility and exercise.
Speaker: And I think that this is really a transformation of the way we care for these patients.
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.
Speaker: But what I would like to ask you are two questions pertaining the early mobility, Julie.
Speaker: First,
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?
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.
Speaker: Any comments from your experience at the VA or with the collaborative on this point?
Speaker: Yeah, that's a great question, Sergio.
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.
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.
Speaker: for a nurse to come and help them go to the bathroom.
Speaker: And all the progress made on their truncal and leg strength in the ICU potentially could deteriorate.
Speaker: So I'll give you an example of one of our top performing hospitals.
Speaker: They took their mobility score that they had modified from the AACN
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.
Speaker: And that way they were using the same mobility scales in the ICU and throughout the hospital.
Speaker: And that way everybody was speaking the same language and could more reliably track the progress
Speaker: or absence of their mobility progression during their entire hospital stay.
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
Speaker: skilled nursing facility discharge rates and correlating that with their mobility levels at the time of discharge.
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.
Speaker: So we really need to continue our efforts throughout the hospital stay.
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?
Speaker: Great question, Sergio.
Speaker: So, Trina, if you look at – let me back up a run.
Speaker: There was a recent worldwide ICU survey published by Morandi and colleagues
Speaker: which looked at sort of the current state of affairs of the A through F bundle in ICUs around the world.
Speaker: And what they found is that when it came to early mobility, although over 80% of the 1,400 respondents from 47 countries
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.
Speaker: So for the collaborative, our definition of
Speaker: early mobility was, at a minimum, was the patient could sit on the edge of the bed with minimal assistance.
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.
Speaker: So that's what we define as early mobility.
Speaker: In reality, most ICUs who claim to do early mobility, less than a third of them,
Speaker: target ambulation of their patients.
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.
Speaker: So most ICUs define their early mobility as either passive or active range of motion exercises in bed alone.
Speaker: which is better than nothing but clearly not enough to really get these patients out and functional again.
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.
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.
Speaker: first day.
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
Speaker: at ICU and hospital discharge, it shortens ICU length of stay.
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
Speaker: functionality or ICU length of stay.
Speaker: So it's not only a question of how we define what early mobility really is, but the timing of it as well.
Speaker: Excellent.
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.
Speaker: So the last component, Julie, of the bundles, the F stands for Family Engagement and Empowerment.
Speaker: And I think a very, very important aspect that perhaps earlier in the ICU days was somewhat neglected.
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.
Speaker: to the well-being or improvement of their loved ones.
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?
Speaker: Well, I think, and this is not just my own preference or bias here, Sergio, but
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.
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,
Speaker: communication and involvement in ICU patient care.
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
Speaker: status of patients and ask them if they have any questions, but it certainly doesn't stop there.
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.
Speaker: And we need to leverage
Speaker: what they bring to that interprofessional team-based approach that's patient-centered in the ICU.
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
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.
Speaker: So I think starting from that premise is very important.
Speaker: But in terms of defining the penultimate way to engage ICU patients and families, out of these 23 recommendations,
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.
Speaker: So what does that look like?
Speaker: Well, first of all, you have to have ICU rounds that happen at the bedside every day.
Speaker: And this is an interprofessional model that should include both
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.
Speaker: But it needs to include the primary provider that is the decision maker and the order writer for that patient.
Speaker: But it should also include other members of the team, so the bedside nurse,
Speaker: a pharmacist and a respiratory therapist, that would be a minimum, but why stop there?
Speaker: You could have dieticians, social workers, physical therapists, palliative care team members.
Speaker: So don't limit your vision for the provider membership on that interprofessional team, but also including families and patients in those discussions.
Speaker: So you need to have those rounds
Speaker: happen at the bedside, not outside the patient's room with the door closed, but actually at the bedside.
Speaker: And that involves going in the patient's room and including them in the discussions.
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.
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.
Speaker: So it's a win-win-win for all parties involved to include patients and families in ICU rounds.
Speaker: And I certainly think that that is a well-received change that we're seeing.
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.
Speaker: I think is very, very refreshing, but also I think makes a big difference for the care.
Speaker: And like you said, it's a win-win-win for everybody.
Speaker: So how should we measure the level of family engagement?
Speaker: Well, that's a very important question.
Speaker: So when we started the ICU Liberation Collaborative, the updated version of the patient and family center guidelines hadn't been published yet.
Speaker: And they came out kind of late in the collaborative process.
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.
Speaker: But once the guidelines came out, that really gave us a very clear roadmap of how to proceed.
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.
Speaker: But actually, there's a really important tool.
Speaker: It's an interactive spreadsheet that's embedded in the published guidelines.
Speaker: It's also available for free on the ICU Liberation website through the Society of Critical Care Medicine.
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.
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.
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.
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.
Speaker: In terms of how you measure that, there's a variety of ways to do that.
Speaker: You can do patient and family satisfaction surveys.
Speaker: objectively measure how many times during the day or week or month patients and families actively participated in round discussions.
Speaker: And again, those guidelines give you some metrics to look to.
Speaker: And I think that that's a great suggestion.
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.
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.
Speaker: And as we all know, critical care, but especially the implementation of these ABCDF bundles is really a team sport.
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?
Speaker: Yes, so first of all, as I mentioned earlier, you want to make sure that the right people are present for rounds.
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
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.
Speaker: That wastes a lot of time on all sides because now those
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.
Speaker: So it's really important to make sure that the right people are on rounds.
Speaker: And the SCCM is currently in the process of writing a white paper on defining
Speaker: who should be on those rounds.
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.
Speaker: And then on rounds, it's important to give everybody a voice to make sure that all the bundle elements are actually addressed.
Speaker: So the recommended format for interprofessional team rounds
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.
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.
Speaker: But that ensures that all the bundle elements are discussed on ICU rounds.
Speaker: Also,
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.
Speaker: So really flattening that hierarchy is key and that requires
Speaker: a culture of mutual respect and effective interpersonal communication amongst team members.
Speaker: Absolutely.
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.
Speaker: And I think that
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 life with their family.
Speaker: But also, I think the second element, I think is very important, is recognizing the value of
Speaker: of each one of our members in the team and what they bring to the table as we implement these bundles.
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?
Speaker: I think that meaningful recognition is an extremely important tool to both accelerate bundle adoption and to sustain bundle adherence.
Speaker: But what do we mean when we talk about meaningful recognition?
Speaker: You know, that's kind of a vague term.
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.
Speaker: and also to give recognition in a way that is meaningful to them.
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.
Speaker: So having the meaningful recognition resonate with your frontline staff, you have to know what they value, what's important to them.
Speaker: But I also think that it's about recognizing not just individuals, but teams to make this happen.
Speaker: Because the A through F bundle is not a nursing bundle.
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.
Speaker: and they're sitting who's going to lead the charge.
Speaker: Well, that's a recipe for failure.
Speaker: You really need to take an interprofessional team-based approach to actually implementing the bundle using continuous quality improvement techniques.
Speaker: And then you have to recognize and celebrate successes of the entire team.
Speaker: And the way you do that is by sharing data and setting goals and showing people where they're going and celebrating
Speaker: when you've made significant progress or ultimately achieved those goals.
Speaker: And that meaningful recognition shouldn't come just from local ICU leadership.
Speaker: It really needs to come from the C-suite to be most impactful.
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.
Speaker: And I think that the other point that I often think about is that the implementation of these bundles is not a destination.
Speaker: It's really a journey.
Speaker: And that it's not like, oh, we already did that.
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.
Speaker: Any comments on that respect, Julie?
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.
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.
Speaker: Whereas the A through F bundle applies to every ICU patient every single day.
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.
Speaker: If you look at the goals of ICU care
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.
Speaker: And we didn't make any movement on the ventilation front.
Speaker: until their lungs looked like they were ready to be weaned and extubated from the ventilator.
Speaker: And we kept them in bed because we thought getting six patients out of bed was bad for them.
Speaker: And we limited family access to our patients.
Speaker: Basically, it was a passive approach to caring for patients, waiting for them to heal themselves, whereas
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,
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.
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.
Speaker: And that requires everybody to see themselves as part of the same team.
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.
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.
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.
Speaker: That's the recipe.
Speaker: for success in successful implementation of the bundle.
Speaker: But once you make that transformation in terms of how you deliver care in the ICU, you won't want to go back.
Speaker: There was a three-month period of time when I was on administrative leave from the ICU in my own unit.
Speaker: And in the meantime, we kept implementing the bundle.
Speaker: And after three short months, I came back to an ICU I didn't recognize, but for the better.
Speaker: And I remember thinking that first day I was trying to conduct interprofessional team rounds at the bedsides of patients.
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.
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.
Speaker: So I think once you see that, it's really
Speaker: transformative in terms of how you view the work that you're doing in your ICU.
Speaker: Absolutely.
Speaker: And I think that, Julie, this has been a fascinating conversation on a very, very important topic.
Speaker: And I think, like you mentioned, it's something that applies to all the patients we see in the ICU.
Speaker: It's about getting every single patient that we treat better as soon as possible and delivering really a much more humane
Speaker: care in an environment that really empowers all the team members to be their best.
Speaker: And I think that we'll have probably more conversations about this topic.
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.
Speaker: Would that be okay?
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?
Speaker: My personal favorite is The Power of Habit by Charles Duhigg.
Speaker: And he talks about what drives our habits in our daily lives, both personally and professionally.
Speaker: And every habit has a cue, a routine, and a reward.
Speaker: And the way I think about
Speaker: restructuring habits in the ICU using the ABCDEF bundle.
Speaker: In the past, the cue has been, oh, this is a really sick patient.
Speaker: The routine has been, we need to keep him in a drug-induced coma until he's better.
Speaker: And the reward is whatever condition the patient emerged from at the other end of their illness.
Speaker: As long as they survive, that was our reward in the ICU.
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.
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?
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.
Speaker: Absolutely.
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.
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.
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?
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.
Speaker: And I think that people who embrace change have a more impactful life.
Speaker: on their fellow human beings.
Speaker: And that's really about what implementing the bundle really means to me.
Speaker: It's about changing the lives of ICU patients that I will never meet.
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.
Speaker: And that's very important to me personally and professionally.
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.
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
Speaker: about the care that we're delivering to their loved ones and how we include them in those care processes in the ICU.
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.
Speaker: The final question just relates to what would you want every intensivist who listens to this podcast to know?
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.
Speaker: Certainly those gains will be realized.
Speaker: even with partial bundle implementation in your unit.
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.
Speaker: And I think that that's a great place to end.
Speaker: I really want to thank you, Julie, for your time, for sharing your knowledge with us.
Speaker: You're passionate about improving lives of critically ill patients.
Speaker: And I think a lot of our listeners hopefully will be inspired and be pushing for these bundles at their ICUs.
Speaker: And we hope to have you back soon.
Speaker: Thank you very much, Sergio.
Speaker: I appreciate the opportunity.
Speaker: Thanks again for listening to Critical Matters.
Speaker: Make sure to subscribe to this podcast on iTunes or Google Play.
