The ABCDEF Bundle: Science and Philosophy of How ICU Liberation Serves Patients and Families
E Wesley Ely, E Wesley Ely
Abstract
Over the past 20 years, critical care has matured in a myriad of ways resulting in dramatically higher survival rates for our sickest patients. For millions of new survivors comes de novo suffering and disability called "the postintensive care syndrome." Patients with postintensive care syndrome are robbed of their normal cognitive, emotional, and physical capacity and cannot resume their previous life. The ICU Liberation Collaborative is a real-world quality improvement initiative being implemented across 76 ICUs designed to engage strategically the ABCDEF bundle through team- and evidence-based care. This article explains the science and philosophy of liberating ICU patients and families from harm that is both inherent to critical illness and iatrogenic. ICU liberation is an extensive program designed to facilitate the implementation of the pain, agitation, and delirium guidelines using the evidence-based ABCDEF bundle. Participating ICU teams adapt data from hundreds of peer-reviewed studies to operationalize a systematic and reliable methodology that shifts ICU culture from the harmful inertia of sedation and restraints to an animated ICU filled with patients who are awake, cognitively engaged, and mobile with family members engaged as partners with the ICU team at the bedside. In doing so, patients are "liberated" from iatrogenic aspects of care that threaten his or her sense of self-worth and human dignity. The goal of this 2017 plenary lecture at the 47th Society of Critical Care Medicine Congress is to provide clinical ICU teams a synthesis of the literature that led to the creation of ICU liberation philosophy and to explain how this patient- and family-centered, quality improvement program is novel, generalizable, and practice changing.
Figures
Map of the United States showing the 3 zones of SCCM’s ICU Liberation Collaborative and the locations of 67 adult and 9 pediatric hospitals (n=76) participating in this large-scale quality improvement initiative using the ABCDEF Bundle to implement the PAD Guidelines.
ICU Liberation is a quality improvement program geared towards reducing symptoms of pain, agitation, and delirium (PAD) that threaten patients’ sense of self-worth and dignity. These symptoms of suffering are monitored using valid and reliable tools, and the culture is shaped using the evidence-based ABCDEF bundle as a rounding checklist. These concepts are based on hundreds of peer-reviewed studies including over 30 from JAMA, Lancet, and NEJM.
A. San Francisco General in 1970 (left) – Mobilizing an intubated ICU patient with primitive equipment. After this period of early mobilization in the ICU, there was a progressive move away from awake and ambulatory patients while on the ventilator towards heavily sedated and restrained patients for days on end to help prevent awareness and reduce memories of ICU stay. (Courtesy of Heidi Engel PT, DPT and Michael Gropper, MD with permission from the patient and institution) B. University of California San Francisco (UCSF) in 2015 (middle) – Mobilizing an intubated patient with advanced equipment including monitors and pumps. This patient provides a visual example of the incorporation of ICU Liberation and the ABCDEF bundle within the same city as Fig. A yet 45 years later, following the ongoing renaissance of ICU mobilization. She serves to counter the idea that only simple patients should be ambulated. This 54 year old woman had acute myelogenous leukemia with chronic graft versus host disease and emphysema. She presented with acute on chronic hypoxemic and hypercarbic respiratory failure. Once on mechanical ventilation, she began ambulating to the edge of the bed on day 2 with family to reassure and calm her. On day 3, she transferred to chair standing with moderate assist, and on day 4 took a short walk on the ventilator, which then grew progressively longer on subsequent days (100 to 500 feet), when she was successfully extubated after a week on the ventilator. In the stepdown unit (think “LTAC”), where sometimes patients regress because things are relaxed in comparison to actively “mobile” ICUs, the family advocated for daily ambulation based on their ICU experiences with her. She was discharged home on day 12 with a home-health physical therapy program, where she continues to be functionally independent. Her survival and independence were not expected by the ICU physicians. (Photo courtesy of Heidi Engel PT, DPT with permission from the patient and institution) C. ICU Patient and Her Husband Walking with Shopping Cart at the Pomeranian Medical University in Szczecin, Poland 2016 (right) – Globally there is a wide range of approaches to early mobilization adapting the ICU Liberation concepts to local resources and cultures. (Courtesy of Katarzyna Kotfis, MD with permission from the patient and institution)
A. San Francisco General in 1970 (left) – Mobilizing an intubated ICU patient with primitive equipment. After this period of early mobilization in the ICU, there was a progressive move away from awake and ambulatory patients while on the ventilator towards heavily sedated and restrained patients for days on end to help prevent awareness and reduce memories of ICU stay. (Courtesy of Heidi Engel PT, DPT and Michael Gropper, MD with permission from the patient and institution) B. University of California San Francisco (UCSF) in 2015 (middle) – Mobilizing an intubated patient with advanced equipment including monitors and pumps. This patient provides a visual example of the incorporation of ICU Liberation and the ABCDEF bundle within the same city as Fig. A yet 45 years later, following the ongoing renaissance of ICU mobilization. She serves to counter the idea that only simple patients should be ambulated. This 54 year old woman had acute myelogenous leukemia with chronic graft versus host disease and emphysema. She presented with acute on chronic hypoxemic and hypercarbic respiratory failure. Once on mechanical ventilation, she began ambulating to the edge of the bed on day 2 with family to reassure and calm her. On day 3, she transferred to chair standing with moderate assist, and on day 4 took a short walk on the ventilator, which then grew progressively longer on subsequent days (100 to 500 feet), when she was successfully extubated after a week on the ventilator. In the stepdown unit (think “LTAC”), where sometimes patients regress because things are relaxed in comparison to actively “mobile” ICUs, the family advocated for daily ambulation based on their ICU experiences with her. She was discharged home on day 12 with a home-health physical therapy program, where she continues to be functionally independent. Her survival and independence were not expected by the ICU physicians. (Photo courtesy of Heidi Engel PT, DPT with permission from the patient and institution) C. ICU Patient and Her Husband Walking with Shopping Cart at the Pomeranian Medical University in Szczecin, Poland 2016 (right) – Globally there is a wide range of approaches to early mobilization adapting the ICU Liberation concepts to local resources and cultures. (Courtesy of Katarzyna Kotfis, MD with permission from the patient and institution)
A. San Francisco General in 1970 (left) – Mobilizing an intubated ICU patient with primitive equipment. After this period of early mobilization in the ICU, there was a progressive move away from awake and ambulatory patients while on the ventilator towards heavily sedated and restrained patients for days on end to help prevent awareness and reduce memories of ICU stay. (Courtesy of Heidi Engel PT, DPT and Michael Gropper, MD with permission from the patient and institution) B. University of California San Francisco (UCSF) in 2015 (middle) – Mobilizing an intubated patient with advanced equipment including monitors and pumps. This patient provides a visual example of the incorporation of ICU Liberation and the ABCDEF bundle within the same city as Fig. A yet 45 years later, following the ongoing renaissance of ICU mobilization. She serves to counter the idea that only simple patients should be ambulated. This 54 year old woman had acute myelogenous leukemia with chronic graft versus host disease and emphysema. She presented with acute on chronic hypoxemic and hypercarbic respiratory failure. Once on mechanical ventilation, she began ambulating to the edge of the bed on day 2 with family to reassure and calm her. On day 3, she transferred to chair standing with moderate assist, and on day 4 took a short walk on the ventilator, which then grew progressively longer on subsequent days (100 to 500 feet), when she was successfully extubated after a week on the ventilator. In the stepdown unit (think “LTAC”), where sometimes patients regress because things are relaxed in comparison to actively “mobile” ICUs, the family advocated for daily ambulation based on their ICU experiences with her. She was discharged home on day 12 with a home-health physical therapy program, where she continues to be functionally independent. Her survival and independence were not expected by the ICU physicians. (Photo courtesy of Heidi Engel PT, DPT with permission from the patient and institution) C. ICU Patient and Her Husband Walking with Shopping Cart at the Pomeranian Medical University in Szczecin, Poland 2016 (right) – Globally there is a wide range of approaches to early mobilization adapting the ICU Liberation concepts to local resources and cultures. (Courtesy of Katarzyna Kotfis, MD with permission from the patient and institution)
Source: PubMed