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The mission to create Awake and Walking ICUs is not a brand new endeavor. Dr. Juli Barr, an early PAD and ICU liberation founder, shares with us the tools needed to master the ABCDEF bundle.

Episode Transcription

Kali Dayton 0:02
Dr. Barr, welcome to the podcast I am ecstatic to have you on. Can you introduce yourself to the listeners?

Dr. Juli Barr 0:10
Sure, Kali. Well, first of all, let me just say it’s a pleasure and an honor to be able to be on this podcast with you today.

My name is Dr. Juli Barr. And I am a critical care anesthesiologist at the VA Palo Alto in California. And I am also professor emeritus of anesthesia and critical care at Stanford.

Kali Dayton 0:40
Those that are listening this podcast, this icy revolutionists that are really deeply immersed in this delirium and mobility scene, they should already know who you are, you’re a big deal. And you’re not going to toot your own horn. But I am, you are one of the early founders of this whole process. And so it’s an honor to be discussing this with you, because a lot of where we are now or what we know now is because of your work.

So thank you and tell us how did this all start for you? What were what first alerted you? To the risks and the harm of sedation and immobility. And then what did you do about it?

Dr. Juli Barr 1:16
So, Kali, I’ve been practicing critical care for over 30 years. And for much of my career, certainly the first 20 years of that career. I thought that drug induced comas in mechanically ventilated patients in restraints and with or without neuromuscular blockade was kind of de rigueur for ICU care for our sickest patients.

And we didn’t kind of lift that veil of care until we felt like the patient was stable enough to tolerate being awake and moving around. And many of those patients, although they left the ICU, they didn’t leave the ICU in good shape. They often had severe physical and cognitive and mental health dysfunction, which we now describe as post Intensive Care Unit or PICS.

But all of us felt like we were doing the best we could, and that that was just an expected outcome of somebody being so sick or so injured. And then in 2005, I was asked by the Society of Critical Care Medicine to update the sedation and analgesia guidelines. And there’s a another story behind that process. It took quite a while but I put together an A-list of my heroes and heroines in critical care to help me revise those guidelines.

And in 2013 (1), the pain agitation and delirium guidelines, republished in critical care medicine, then, in 2014(2), I was part of a committee that launched the ICU liberation campaign to help promote these guidelines. And in 2018, a revised version of those guidelines known as the PADIS guidelines (3) were published, which now placed to additional emphasis on mobilizing patients and promoting sleep.

And it’s been 10 years since the PAD guidelines were published. And it has become my passion and my singular focus, to make sure that every critically ill or injured patient, adults and children receive the benefits of the ICU liberation bundle wherever they are in the world. So that’s how we got to this point.

Kali Dayton 3:54
That’s a huge impact. You truly have I mean, those guidelines are referred to over and over again, obviously, there’s a gap in complete compliance or perfection of those guidelines. But the changes that have made I think, are a lot in part because of your work. And you had some interactions with the Awake and Walking ICU. How did that happen? And how did that impact how you approached these guidelines?

Dr. Juli Barr 4:22
So I actually spent part of my training in Salt Lake City under Dr. Terry Clemmer(4), who’s one of my great heroes. And I also know Polly Bailey, who worked closely with him and they were some of the early pioneers in mobilizing ventilated patients, mechanically ventilated patients as well as patients on ECMO.

And they tried to spread that through out the ICUs that they had influence over with some success. But that was was really the beginning of my experience in understanding that that was even a possibility for very sick patients. But I didn’t really see that as being something that necessarily could be replicated outside of that setting, because those were special people with teams that they worked very closely with.

And in my experience, most ICUs weren’t focused on that and making it a priority. So it really took understanding the literature behind early mobility. And understanding that the only way you can mobilize critically ill patients is to make sure that, number one, their pain is well controlled number two, that they’re awake. And number three, that they’re not delirious so that they can cooperate and follow commands and do what you need them to do.

So when we think about ICU liberation, and the ABCDEF bundle, the I like to talk about that not as a series of sequential letters, if you will, but I’d like to talk about the house that PAD built. And the foundation of that house is the pain agitation and delirium or assessment tool. So we know that the numerical rating scale and behavioral pain scales like CPOT and BPS are the gold standard, preferred pain assessment tools.

We know that the Richmond agitation sedation scale and the sedation agitation scale, are the gold standard sedation tools and then we have the CAM ICU and the ICDSC as delirium assessment tool. So that’s one of the things that came out of the PAD guidelines was helping people to find the right tool.

So picture that is the foundation of the house. And then the framing of the house is how you operationalize the guideline recommendations around sedation practices around analgesia practices, so envision protocols and order sets that are heavily developed in conjunction with ICU pharmacists, as well as shifting away from pharmacologic management of delirium and focusing more on what I call kind of the “David Letterman top 10 list of non pharmacologic delirium management practices”: reorientation, mobility, promoting sleep, et cetera, et cetera.

And, and then the roof of the house of pad is really early mobility and, and family engagement. Oh, and also, the framing of the house, of course, would include SAT SBT trials. So you really can’t mobilize patients easily. If you haven’t built the house from the ground up, you can’t start with the roof and expect it to hover in space.

Kali Dayton 8:08
I had an experience a few months ago, where I went on site to a team that I didn’t do webinars or anything with and beforehand, and I was introducing myself to the medical director. And he knew that we were there to focus on early mobility. But when I mentioned I was there, also to help their delirium and sedation practices. He looked really confused. He said, “But you’re here for mobility. Why are you talking about sedation?”

And so you just reaffirm exactly my same approach is, there’s no way there’s no way you can mobilize unless you’re really focusing in addressing the sedation and delirium piece.

Dr. Juli Barr 8:42
Right. And I think that’s why the Awake and Walking ICU notion is so important, because those two things do go hand in hand. I would say that, when people are first learning about I see liberation, and they look at this bundle. And they might think that they need to take one bundle element at a time and into and implement that.

And perfect that before they then move on to the next bundle element. But in point of fact, there’s a method to the madness around why these individual interventions have been bundled together, because we know two things about this bundle that the sum is greater than the parts.

So there’s definitely synergistic benefit around optimizing pain, sedation and delirium management on the one hand, and being able to get patients off the ventilator sooner and get them out of bed faster and be able to engage with family and providers and get out of the ICU sooner in better shape.

So there’s the synergy of it. And we also know from the ICU liberation collaborative as well as other studies that that there is a dose response effect with a bundle. So you don’t have to be perfect at doing all the bundle elements for all patients every day, if if you do some of the bundle, reasonably well, you will definitely see a benefit.

But the better your bundle performance, the better those, the greater your return on your investment, so to speak. So we know that when bundle compliance achieves about a 60% threshold, that’s when things really take off. So you don’t really have to do everything perfectly every day. And you know, Perfection is the enemy of the good. So it’s important to get out there and try to do some aspects of the bundle, but look at it as a bundle and not as individual elements.

Kali Dayton 10:48
Which is so validating because I’ve had teams approached me saying, “We want to work on Early Mobility,” or “We want to work on awakening trials.” And when I suggest it’s really hard to do one or the other, it’s really hard to focus on avoiding sedation, when you don’t have mobility up your sleeve as a tool to treat agitation, delirium, anxiety, all those things, because then any patient in the ICU is at risk of developing delirium.

But then what do you do when they do have delirium, and you don’t have mobility as part of your practice, it’s really hard to keep these patients calm, cooperative, compliant, and safe, unless you have mobility going. And then also, it’s obviously hard to mobilize them if you’ve started sedation, not taking it off until days Two weeks later. And I people kind of, I think, have perceived, I started this phrase “Awake and Walking ICU” to describe that specific unit that I was coming from, because I didn’t want there to be legal complications when I did this podcast.

But I did find that that phrase, that title has an impact, right? You immediately get this image which is accurate to what that ICU is usually like, right? Most patients are Awake and Walking. But I never intended for it to be a separate thing. In my mind, and in reality, what you’re describing is that the Awake and Walking ICU was a mastery of the ABCDEF bundle. It’s full ICU liberation, these patients are fully liberated from the sedation, from delirium, from immobility, and they’re off the ventilator liberated from the ventilator and out of the ICU much quicker.

So all of this is synergistic. It all ties in together. That way, can I can I see you as just the 100% all the way. But I’ve seen with patients or with teams, quickly, they see outcomes, right? I do webinars with them, they start to lighten their sedation, take it off sooner do more waking trials, I show up and they say we’ve had a 40% reduction in restraint use already.

Even before mastering, avoiding sedation altogether, or mobilizing patients right away, they immediately see an impact. So all of this is very validating. And I think it’s important have a picture of what we’re working towards. But again, it’s the bundle, it’s a framework to utilize as we customized care for each patient.

Dr. Juli Barr 13:06
Right. I couldn’t agree more. And I think it really starts with using the right tools to assess pain, sedation, and delirium and patients. Because if you’re not using the right tools, or you’re or you’re not assessing patients, at all or infrequently, then you’re going to overlook the things that you’re trying to avoid, which is poorly treated pain, deep sedation, and delirium.

And there have been studies across all three of those domains showing that just using an assessment tool that’s been validated, it reduces the incidence of of those states and improves care (5), independent of ICU liberation. So people have to adopt those assessment tools before they make the leap to these higher order activities. That’s the first thing I wanted to say. The second thing is getting back to the awake and walking versus early mobility, terminology for mobilizing patients.

You know, walking is more explicit than mobility. And I think when we talk about “mobilizing patients in the ICU”, that means a lot of things to a lot of people. So for some people, mobilizing patients means we’re doing passive range of motion. And we know that that’s better than nothing, but that’s not the level of mobility that makes a difference in terms of getting them out of the ICU sooner and in better shape than they would have been otherwise.

So what the evidence tells us is that the minimum level of mobility that makes a difference is if somebody can weight bear, and what weight bearing looks like to start with this is your floor is being able to sit on the edge of the bed without any support, nothing behind you holding you up, no people holding you up. Because that indicates that you have enough truncal strength to support yourself being upright.

Why is that important because truncal strength is a strong predictor of the ability to wean from mechanical ventilation. So you start with that, and then you build on that. Now, there are some patients that weren’t walking before they came to the ICU. And we’re not trying to perform a resurrection here.

But you do want to try to maximize every single patient’s mobility level, to the extent that you can as early as possible, because we also know that the evidence tells us that patients that lie in bed for a week and don’t get out of bed, lose 30% of their muscle mass, and their skeletal muscle strength.

So ICU-acquired weakness is a real thing. And it happens much more quickly than people realize. And that’s why from the time somebody comes to the ICU, the clock’s ticking, so it’s not just about what we’re going to wait for them to get well enough, and then we’re going to talk about getting them out of bed.

And if that first week has gone by, you’re really facing an uphill battle. And ICU acquired weakness isn’t a disease of the elderly. It affects anybody of any age, even children, if they’re immobilized, and it’s not just about not moving around, it’s about the catabolic state of critical illness and injury that accelerates that loss of muscle mass, you’re basically catabolising, or, cannibalizing yourself to try to stay alive and your muscles aren’t really being used for very much. So the body’s like, “Hey, we got a calorie source here. Let’s capitalize on that.”– So that’s why it is so important.

Kali Dayton 17:04
Yeah. And in addition to receiving myotoxic sedatives, right?Propofol is just toxic to the mitochondria. And it’s just exacerbating that whole process and expediting the muscle loss. And I love that you bring up that the true ICU liberation is not “start sedation, wait till later, wait for ventilator settings that are minimal and then start to rehabilitate them at varying levels”.

The REAL ICU liberation is: “Let’s prevent the harm. right away as soon as possible.”– But that’s been misinterpreted. I mean, culturally, I think in the 2000 and teens, you had this ICU liberation rollout, we made headway we had momentum going. And somehow we kind of slipped back into where we were before.

And the sense that I get through the community is this perception that you’ve described, Let’s, let’s take care of those…… early mobility, delirium…. on the back-end, and then do awakening trials, once ventilator settings are minimal, and then even help waiting trials are performed.

There’s really not a strong united front as to assessing for delirium during the awakening trials and quickly treating the delirium and being aggressive about it. It’s been somehow misinterpreted. I know that was never any of the team’s intentions when you developed and rolled out the ICU liberation bundle. So what are your thoughts on that as to where we are now?

Dr. Juli Barr 18:32
I think and what I’m saying is, is unrelated to COVID. But in general, if you even before the COVID pandemic, there was a lot of misunderstanding about the importance of being aggressive and weaning patients off the ventilator, and getting them out of bed sooner. I completely agree with that.

But I think having a systematic approach to those two things, so every single day, you’re going to screen patients to see if it is appropriate to wean them not based on “Dr. so and so” who just doesn’t like to wean patients based on their own personal and professional criteria, but you actually have an SAT SBT trial with built in safety screens to perform both of those steps. That’s essential.

There has to be a common checklist, like a pre-flight checklist before the plane takes off, to make sure it’s okay for the plane to take off. So same thing with mobility. You want to screen patients to see if they meet certain safety criteria. But once you’ve done that, nothing should hold you back from trying those two interventions. So I think it all starts with a protocol that is based in evidence and has very specific criteria for go no go. I don’t think continue that has to be done every day.

Kali Dayton 20:11
I just talked about the evidence. I always have this question as when it’s based on the evidence, there’s no evidence to support automatically sedated patients, after intubation. How do you think that’s been perpetuated? Like, why are we still stuck in this automatic sedation after every intubation until ventilator settings are minimal? What are your speculations?

Dr. Juli Barr 20:36
Because I don’t think a lot of people have considered the alternative. I mean, it’s true, you have to sedate somebody to actually intubate them. Absolutely. But once they’re intubated, and usually you’ve intubated them because of some acutely unstable state.

So in that immediate period, you definitely have to make sure that the boat is not still trying to tip over and that you have halted whatever their precipitous decline was that led to their intubation in the first place. But where that point of stability, it is reached, or when it’s reached, and pivoting to the alternative, saying, “Okay, well, now that the patient is stable, we can begin to move towards peeling these interventions back starting with sedation, because you’re not going to get them off the ventilator if they’re in a coma.” So I think, again, having very specific criteria for weaning sedation, which is what an awakening trial is, really brings to the table is imperative. Absolutely. And doing that every day.

Kali Dayton 21:53
I love it. And the I think teams make the biggest impact when they question whether or not that’s because they’re intubated.

Dr. Juli Barr 22:03
I think that you have to ask the question, you and you have to do that in a team based approach, you can’t just have that little thought in your own head and never articulated. So it takes courage.

Kali Dayton 22:14
To bring that up, though, for for clinicians, if it’s one lone nurse, listen to the podcast and realizing, “oh, intubation, mechanical ventilation does not automatically equal continuous sedation, especially deep sedation.” How, how do I even approach this with my teams? It can be a daunting task to be that one revolutionist.

Dr. Juli Barr 22:32
It’s also arguably easier, I think, to care for a patient that is not thrashing around and trying to pull their breathing tube or lines out. And so there is that convenience factor and, and that’s to take nothing away from my nursing colleagues, because I think physicians and respiratory therapists become part of that problem.

Like, it’s just easier if we don’t have to watch them like hawk and worry that something bad is gonna happen. And then we are I am going to be blamed for whatever that badness was. So I think I think there is some of that, but that that is remedied through education and role modeling and leadership.

Kali Dayton 23:20
Absolutely in having a team approach, and a process of care that prevents that scenario of agitation and thrashing, right, the “Sooner we roll back that sedation, the much safer our patients are going to be” — and our clinicians are going to be, and that’s something I think, helps with the buy in.

Over time when they realized that “If I take off sedation sooner, I don’t have this scenario later.” Because that’s how I learned awakening trials in 2016. As a travel nurse, I think it was one of the facilities that was part of the early rollout. It wasn’t a formal training. It was just my orienting nurse saying, “Hey, we do this thing five in the morning, and we turn down sedation and you just when you start to see them thrash to turn sedation back on and chart, an SAT”—

and that’s what I was taught was an SAT. And so I think when that’s the approach, that’s all a nurse gets to experience is a patient coming out thrashing. And now that I’ve learned more, and there’s in the ICU liberation bundle, I realized that that was, that’s not the purpose. That’s not the vision of it. But that’s been a hard thing that has been, I think, forced on nurses is that they’re alone in doing this awakening trial.

They don’t know why they’re doing it, they don’t have the tools to respond or treat that agitation, that delirium, and so they’re stuck kind of restarting that sedation. And I’m assuming I can tell by by interactions with you, that was never the purpose, but we have some some barriers that have been created to that impede us from mastering the bundle.

Dr. Juli Barr 24:47
Well, I agree with you. I think that if you don’t give people alternative strategies to manage a patient and you know, not every problem is a nail that requires a hammer, but if sedation is the only tool in your toolbox and you’re going to look at everything as though it’s remedied by having a hammer.

So I think that’s one important factor that another thing that we’ve kind of touched on but I want to explicitly address here is some of the other challenges around conducting SAT SBT trials and early mobility. So unlike pain assessments and management, and sedation assessments and management, those which which can be protocolized, right, you give you do this pain assessment, and if their number is above this amount, you’re going to administer whatever the prescribed pain regimen is for significant pain.

And if you have a sedation protocol, and it instructs you to maintain light sedation with some specifics about how to titrate, whatever sedatives you’re using, then that can be more or less executed by the bedside nurse with guidance from pharmacy and the physician team. But when it comes to doing SAT trials, and mobilizing patients, that’s much more of a team sport, in terms of the hands on nature of it, and that requires multiple people to be at the bedside to execute those steps.

And if you look at bundle compliance, Morandi (8) and colleagues did a worldwide survey in 2017 of of bundle element compliance, they found that pain and sedation management and to a somewhat lesser extent delirium management were the top performers. But then you looked at SAT trials and early mobility, and family engagement, and they were like, half or less in terms of market penetration, if you will have a bundle element compliance.

And I think and especially for SATs, beauty and mobility, it’s, it can be really challenging to have everybody at the bedside when you need them. And I hear that all the time. When I talk to hospitals and healthcare systems, it’s like they want to do an sh t SBT trial. But you know, the, the nurse starts there, as at trial at 5am. patient wakes up, they’re ready to have their SBT trial. But guess what? No, our team is too busy. And so they turn the sedation back on because our team didn’t show up for them.

Kali Dayton 27:36
And they’re they’re restless or agitated. Or the perception is we’re just doing the awakening trial just for the breathing trial. We’re just doing it to assess for extubation not only with expectation expectation to have sedation off to have awake and communicative patients, but it’s like if we’re not going to do a breathing trial, that moment. Well, there’s “no reason to have sedation off” is a lot of the perception I get.

Dr. Juli Barr 28:01
Right, yeah, so that’s part of the problem but but having the availability of the RT at the bedside, and to have that conversation with the nurse about. “Okay, now we’re going to start the SBT trial and continuing to have that conversation throughout the SBT trial.” So it shouldn’t just be a hit and run. You know, waiting for the nurse to call because the patient’s now bucking the ventilator.

And I want to say a word about SAT trials because, you know, it’s one thing to look at guideline recommendations. It’s another thing to operationalize those recommendations. And I think one of the things that people struggle with when it comes to SAT trials is people think they should turn off anything that sedating the patient.

So that’s not only a sedative hypnotic, but also an opioid infusion. Okay. But if that opioid infusion was actually helping to mitigate significant pain, and now you’ve turned it off, when that patient wakes up, and they get agitated, because now they’re in pain, that doesn’t mean you should just turn everything back on. As it was before. You have to assess the patient and decide, “Well, maybe you know, a little Dilaudid bolus would be appropriate here rather than putting him back to ‘sleep’ with the, you know, Dilaudid infusion and the propofol infusion.”

So, you know, empowering the bedside nurses and RTs to actually smoothly coordinate and execute SAT and SBT trials through protocolization. And giving them more than a hammer to respond to every problem is is really key. And the same is for early mobility.

You have to have a patient who’s awake and cooperative and pain free and not thrashing around to get them out of bed but also, you need more hands on deck to make sure that you can save really mobilize those patients. And I think a lot of hospitals never get to that point because they think that other person that should be at the bedside to help them mobilize, somebody should be a physical therapist.

And there’s a problem with that, because hospitals don’t have physical therapists, unless you’re UCSF with Heidi Engel, that that have physical therapists that are dedicated just to the ICU. They’re elsewhere. And also, the payment and reimbursement models for physical therapy do not reward hospitals, for paying for physical therapists to work in the ICU, where they make their money is on the pre discharge planning for physical therapy after they leave the hospital. So it’s just this crazy upside down system.

So if it’s not going to be a physical therapist at the bedside, then to help you mobilize that patient, then who should that be? Well, a physical therapist should definitely advise the team about strategies for moving towards a higher degree of mobility.

But when it actually comes time to get that patient sitting up on the edge of the bed, if they’re on a ventilator, it’s important to have the RT there to help because maybe you want to disconnect the patient and bag them transiently to transition them to an upright position.

Maybe you want to change their ventilator settings to transition them to an upright position. So having an AR T there for the mechanically ventilated patients is imperative. If you need more people than that, honestly, nursing assistants, med techs, med students, nursing students, physicians can can help with that mobilization process.

And then once they’re up walking around, in our ICU, it’s basically one person following behind the patient pushing a walker, and maybe helping with the equipment. But it does not require a physical therapist to come to the bedside to get every critically ill patient out of bed period, hard stop.

Kali Dayton 32:45
And in that Awake and Walking ICU, we would do two sessions, usually with physical therapy. They weren’t there for every patient. But they were only there during the day. And then we would do mobility session with our patients at night, like eight to 10 and 11 o’clock at night, we were doing usually walking patients, again, it’s the highest level of mobility that they can, that’s what we’re striving towards.

So I as a nurse walked my patients with an RT and CNA all the time. But because during the day shift, I kind of learned from physical therapy, how to do that I had those skills, our CNAs had those skills, RTs weren’t fazed by it. We developed that skill set.

We also because of doing it early on in an ICU admission. It minimized the complexity of these patients, they were stronger, they were easier to mobilize. So I think there are lots of factors that make it so that it doesn’t have to be physical therapy alone doing it every single time.

We can save their expertise for the more complicated, tenuous patients, when everyone understands that what Chris Perme says that “Mobility is everyone’s job.” And when it comes to utilizing or having more resources for this, some teams don’t have techs. They don’t have extra people, which is blowing my mind.

And so I’ve been doing financial presentations to hospital systems to try to show them how expensive it is when a nurse has to increase sedation to go answer a phone. But I think a lot of that what’s really helpful and advocating for these resources is to show the data to show the length of stay delirium rates, the complications that happen, that could have been avoided if we had more support more resources, better protocols and training in our teams.

So I also wanted to pick your brain about data collection. You recently talking about this at SCCM your kind of expertise on it. Why is that so important and guiding our practices?

Dr. Juli Barr 34:41
Great question of you don’t know what you don’t measure. So if you’re not measuring your performance and your outcome, and the impacts of your good intentions on other aspects of the care process, then it unlikely that you’re going to improve very quickly, very significantly, or be able to sustain those gains.

Once you achieve a certain level of performance, and EHR integration of bundle metrics, is a critical aspect of performance measurement. I’d like to think that we’re beyond, you know, manual data collection for quality improvement purposes. But getting getting the right metrics into the EHR systems, and then, more importantly, being able to get them out again, for not only improving care at the patient level, but the unit level and for longitudinal quality improvement purposes.

That’s the tricky part. And it inquires involvement by EHR manufacturers who have to be sold on the idea that these metrics are important enough to include them in their standard ICU platforms, not some bowtique add on that you have to pay extra for to have access to.

And, and then you also have to, even once you get the metrics in there, people have to know how to be able to access them at the bedside, and to for quality improvement purposes. So that requires a fairly heavy lift, by IT departments at a hospital level. And the problem with that is, is that it resources are scarce, in every hospital, we’d all like to have more IT support, right.

But the allocation of those IT resources are driven by the powers that be in the C suite, who if they lack the understanding of the importance of ICU liberation to their bottom line, they are not likely to allocate the necessary IT resources to the ICU, to make the ICU liberation bundle metrics, seamlessly integrated into the daily workflow of the unit.

Kali Dayton 37:37
Yes, I think there’s a lot of evidence, I mean, I have Episode 95 (6), showing the financial picture, I can do these presentations using just the studies, the generic data that we have showing that the complications that come from not complying with the bundle are extremely expensive to hospital systems.

It’s also even more powerful to say, “Here are the rates of those complications in your system and your hospital, here’s what you specifically are paying.” But that does require data collection. So I think there’s easily an argument to be made without your specific data. But it’s so much more powerful when you have your specific data to your team available to prove the gaps in your care and the repercussions of it.

Dr. Juli Barr 38:19
Well, the good news is, is that somebody else has already done the work showing the difference in EHR integration of the bundle on ICU outcomes. So John Brown (7) and colleagues down at USC on their Cerner platform, integrated the bundle metrics throughout their hospital, and they had eight different ICUs in their facility. And they basically randomized the ICUs are divided them into two groups. Four of the ICUs were the control group ICUs, and the other four were the intervention ICUs.

And then the intervention ICUs. All the staff received bundle related education, data literacy training around the bundle metrics, and perhaps more, most importantly, they received weekly bundled performance reports that were extracted from the EHR. Now the other four ICUs had access to the same bundle metrics in their EHR screens, but they weren’t given those three interventions.

And then they measured bundle compliance and ICU outcomes in the two cohorts, and found that over a 15 month period, which included the first three months of the pandemic, that in the intervention ICUs that bundle compliance more than doubled, and was sustained throughout the study period, including the first three months of the COVID 19 pandemic, by contract.

So in the control group, there wasn’t any significant improvement in bundle compliance over time and wait for it. During the pandemic period, that three month pandemic period, their bundle compliance actually fell below their baseline, which is the story in the vast majority of ICUs, in terms of how they responded to the COVID, 19 pandemic, you know, the bundle just kind of got thrown out the window, and we went back to the 1990s, of, of critical care medicine. So it makes a difference.

Kali Dayton 40:30
Yeah. As a nurse, obviously, charting is laborious. I think we make it way too complicated. It distracts us from patient care. But why is so charting on the bundle is important for data collection to understand where we’re at where our gaps are, and such, but how does it impact patient care in the moment? Even how we interact with our colleagues and the different disciplines when we are having that prompt from EHR?

Dr. Juli Barr 41:00
I want to make sure I understand your question. So it sounds like how do we justify the additional work that the nurses have to do to chart on the bundle in terms of demonstrating an immediate benefit to patients?

Kali Dayton 41:15
Yeah, what did that study show us about? Perhaps the impact of understanding why we’re doing the bundle and then having to chart on it every day?

Dr. Juli Barr 41:25
Right? Well, during the ICU liberation collaborative, I would go around to different ICUs that were participating in the collaborative. And, you know, we emphasize the importance of the nurses doing the pad assessments, pain, sedation, and delirium assessments and charting them in the in their EHR, along with the other mental ailments.

But that was, those were the things that they had the chart on the most frequently, and I remember, hearing from many, many bedside nurses is that they would dutifully chart on the pad assessment tools. And then the team would come by and round on the patients. And the nurses would say, “well, their CPOT was five, and their RASS score was positive two, and they were CAM ICU positive”- and they would just get blank stares from the audience.

And, and they would just move on to talking about something else. And the nurses would then say, “Well, I don’t understand why I’m doing all this work to assess these patients, then add chart chart on them, and, and then find out, you know that the team doesn’t really do anything with that information.”

So the upshot of it is, is that although measurement is important, you actually have to act on the details of those measurements and do something with that information to improve the care of patients. So I think that’s the most immediate example of positive feedback that we can give to the nurses who do 98% of the charting on these patients.

Kali Dayton 43:18
When I train teams, I’m teaching pharmacists, respiratory therapists, physical occupational therapists, the physicians, in addition to the nurses, right, harass the camp, so that they have that common vocabulary, and they can actually discuss it together and work on it together, because that’s the exact scenario that I’ve seen repeatedly, that the nurses will say that “patient’s CAM positive”.

And yet, no one knows what that means. And then they can’t, though nurses are left alone to deal with it. So now they’re in charge or turn on it, assessing it, and now intervening on their own. But when everyone understands how important it is, and then being able to track those measurements, it’s it’s been really helpful to reaffirm to the teams the impact of their changes.

So to say, “Here are the delirium rates, and we started, now, months later, taking this approach- mastering the A to F bundle improvement documented, we’ve had a 50% decrease in delirium.”

And because now they understand why delirium is so dangerous, and they’re concerned about it. They’re excited, they feel really validated, and seeing that reflected in the data that their efforts have made an impact in that they’re saving lives with it. And it just perpetuates, and then we can take that data to the C suite and say, We know that delirium decreases or increases healthcare cost by 40 per 39%. We decrease the rates by 50%, or we’re having this impact. How are you going to support us in doing it more? Right? It just carries that conversation.

Dr. Juli Barr 44:43
So I want to talk a bit about measures and how to think about measuring performance around the bundle. So the SCCM has developed what we call the minimum data set. These are basically evidence based metrics around each individual bundle element and For the last five years, we’ve worked very closely with our colleagues at both Epic and Cerner to integrate the standard set of metrics into their two basic ICU platforms.

And the good news is, is that we’ve done that we’re a bit farther ahead on the adult side than the peds side. But both platforms have the minimum data set in them. So what we want to do is make sure that everybody’s measuring the same thing. So ICUs can benchmark themselves and against other ICUs and healthcare systems. So you have to come up with a common set of measures now. But that’s not enough, you have to not only see the data, as I said earlier in a user friendly form, so both platforms have a thrift bundle dashboard.

So it’s kind of a one stop shop, where you can see all the bundle elements at the same time. And both of them have now developed aggregated data reporting around all the bundle elements. And although each of them do this in their own unique way, at the end of the day, whether you’re an epic user or a Cerner user, you’re you should still be able to access data at a patient level, a unit level, if you’re a charge nurse trying to figure out where to allocate your resources and what work has not been completed towards the end of the shift.

And, and then aggregated the identified data for quality improvement purposes, that you can drill down on that data. If you’re having a problem with, say, deep sedation on the night shift. Compared to the day shift, you can drill down to the shift level, you can drill down to the provider level with these reports.

So they’re really powerful tools to answer very sophisticated questions about what’s getting in the way of our bundle performance. But to access those wonderful things within those EHR platforms, you have to have local IT support to help you get there because the one of the strengths and weaknesses of EHR platforms.

And this isn’t unique to Epic and Cerner, but they don’t want that they want to give users the opportunity to customize their platforms. So you do need to invest locally in pulling that bundle data to the surface of your epic or Cerner platform. Now, those two EHR companies only control about 65% of the market share.

And there’s another 10 or so companies in the in the acute care space, that other ICUs might be using like Philips, or clinic con or if you’re a VA system Pisces. And they don’t necessarily have the minimum data set in their platforms. So SCCM is working is beginning to work with some of these other manufacturers and coming up with some agnostic third party solutions to help ICUs that use different EHR systems to also access the minimum data set, because we feel like every ICU should have access to this.

Now, the measures when you talk about process improvement, it’s important to measure both process measures in terms of how you’re actually executing the bundle elements as well as outcome measures. So if if we know from the evidence that mobilizing patients to a mobility score above two and the AACN mobility scale, is associated with improved outcomes, we would be looking at the proportion of mobility scores across patients, their highest mobility score prior to ICU discharge was greater than two yes or no.

And then what was the length of stay in those patients depending on their mobility score. So you’re looking at process measures, you’re looking at outcome measures, but you also have to look at a third type of measure, which is balancing measures. So one of the reasons one of the barriers to getting patients out of bed is that people are concerned that patients will inadvertently become prematurely extubated or fall.

So you also want to be looking at those balancing measures has our rate of premature extubation has gone up as our rate of falls gone up in the unit to make sure that in executed in executing your good intentions around the bundle that you’re not also causing unexpected harm.

Kali Dayton 49:52
And I think those measurements can also provide it’s more security and reinforces good practices. You know, unplanned extubation is one of the biggest fears for early mobility. But when we look at the 10s of 1000s of events record in the research, we see a point 0.6% adverse event rate that include all sorts of kinds of events, as well as unplanned extubation.

So when we can show that kind of data we can show, this is much safer than you perceive. And even on our unit, here are our rates of that. And it just helps everyone feel better and understand the reality and make sure that their fears and concerns are in the right places.

Dr. Juli Barr 50:29
I think you really touched on an important point, Kali, is to help people understand that their ICU isn’t really that different than other ICUs. And they too can be successful in those same ways and and not cause unexpected harmed and part of part of pitching the ICU to people and getting their buy in and support for it. It’s about storytelling.

It’s not just about showing, you know, “we shorten the length of stay by half a day.” Oh, you know, what does that even mean to to a bedside clinician, because in their practice, they’re just focused on what’s right in front of them, the patient that’s right in front of them. So I think storytelling is incredibly powerful. And that is often telling a story about one patient on one day, that did something amazing.

And not everybody was there to see it. But you know, somebody has a picture of it on their iPhone, they can share the staff meeting, some people can just tell a story at you know, during morning report, somebody can, that patient might come back to the ICU and talk to the staff about how meaningful it was for them to be able to get out of bed for the first time. So storytelling is really a powerful tool in successfully implementing the bundle. Absolutely.

Kali Dayton 51:53
When I visited Dr. Mikita Fuchita at the University of Colorado, I already saw the posters, they were posting about the biggest winner and they had pictures of patients. And they made a big deal out of it, they celebrated those victories, and that was changing the culture. So that is, in addition to the data, sometimes, the anecdotes are even more impactful to clinicians than the data.

Dr. Juli Barr 51:53
I agree. You know, Kali, I want to touch on one thing before we run out of time here, you know, I think, I hope that people who listen to this podcast, if they haven’t bought into the value of ICU liberation, that this will begin to open their eyes and ears and hearts a bit around thinking more deeply about how they can implement these best practices in their in their own units.

But for those people who have already drunk the Kool Aid, they’re probably asking themselves, “Well, I already know how good the bundle is. But there are so many things getting in my way in the ICU.”— And I just want to talk for a moment about the the organizational characteristics that can make or break bundle implementation.

So we know from studies, including a large statewide study in Michigan, who, you know, is as a state farther ahead by a couple of standard deviations in critical care quality improvement than other places aren’t necessarily, but but we know that there are four pillars of organizational structure that heavily influence whether ICUs are successful or not in implementing the ICU liberation bundle.

One is staff education. So why is this important now more than ever before? Well, before the COVID pandemic, you know, people were aware of the bundle. But the pandemic changed pretty much everything in critical care medicine, but most notably, it caused a huge attrition of ICU staff, nurses, physical therapists, respiratory therapists, doctors, who had a lot of institutional knowledge, history and experience with ICU liberation, and they left and hospitals scrambled to replace those people. And schools scrambled to train more of those people.

And now what we find is that the people that we’re hiring in our ICUs have less than two or three years of experience right out of school and wait for it, you know, throughout their entire training period, the pandemic was going on, so they weren’t even going to the bedside for much of that time. And they were doing virtual learning and classroom learning and simulation learning.

And so what we have is this growing large cohort of of newbie staff who have no no But your experience about ICU liberation because they’re not teaching it in school. And and they have even less experience than their predecessors in how much time they’ve spent at the bedside. So we need to acknowledge that. And we need to focus our educational efforts on on those newly hired staff. And we need to take it back one step further.

And get this into the curriculum, nursing schools, respiratory therapy, training programs, and medical schools, and physical therapy, schools, and pharmacy schools, we need to dial it back and not wait until we’ve already hired somebody who knows nothing about this. So education is number one.

The second pillar is creating a climate of teamwork, because I see liberation is a team sport. And it requires interprofessional communication, collaboration and care coordination around the bundle. It’s not a nursing bundle. It’s not a Respiratory Therapy bundle, it’s everybody needs to be on board with the bundle. So what does that look like?

Well, the low hanging fruit around facilitating communication, collaboration, care coordination is interprofessional team running at the bedside very at heartstopper. Now, a lot of ICUs already do that, yay, you’ve already got an infrastructure and a framework to begin to have these bundle focused discussion and goals of care discussion that are less data driven, and more outcome driven around the bundle.

But flattening that hierarchy, getting rid of the traditional model where the physician is at the top of the pyramid, and he or she is making all the decisions and people are writing orders and then going out and executing those decisions. No, the physician should be the facilitator of a democratic discussion, and a circle of people where the patient’s at the center of that discussion with their family, ideally, actually, at the center of that discussion.

So going to the bedside in people that are not on contact, and other forms of isolation, which is what many people were doing before the pandemic, and we need to get back to that. Yeah, and with a family there, I love it with the family there, right and inviting them into round two. And I know that’s scary for a lot of people. And that’s another podcast, but

Kali Dayton 57:16
that I’m gonna hit on!

Dr. Juli Barr 57:18
teamwork and and flattening the hierarchy, and creating structured ways where people are more likely to communicate, we talked about sa tsp tea bundles and protocols and mobility protocols, where it becomes part of the workflow every day where people have to communicate and work with each other.

The third pillar is leadership. So ICUs cannot improve in a vacuum. They need C suite sponsorship, not just tacit, yeah, you go off and do that ICU liberation thing. Good for you. We heard that’s a good thing. No, they need somebody to sponsor them, they need an executive that will walk through the ICU that will participate in ICU liberation, quality improvement efforts in a meaningful way.

And why is that important? Because people in the C suite set the priorities for the health care system and the organization. So they’re the ones who come up with a strategic plan of where they’re going to focus resources to achieve those goals. And ICU liberation has to be on that menu of priorities.

So it’s up to us to sell that to the people in the C suite, which means we have to learn how to your point earlier, to translate all the bundle benefits into something that’s meaningful to them. And quite frankly, at the end of the day, it’s always about the money, which is it’s also about rehearsing risk, but reducing risk is still always about the money.

So we need to do a better job of, of communicating and working with the finance people, which also requires permission from the C suite to demonstrate the value of ICU liberation. And, and also other important things that leaders can do is that they can say to the organization, this is what we’re going to do so that the physical therapy department doesn’t feel like they’re stuck between a rock and a hard spot and making sure they have all their discharge planning done.

And “oh, by the way, could you also allocate some resources to the ICU?”, and they’re like, “We only have so many people!” So they also set the institutional priorities. And then finally, they also helped to allocate resources and overcome organizational barriers that the ICU in its little foxhole cannot attend to by themselves. So if they need more IT support, the C suite people are the people who give them permission to do that. So the third pillar is leadership.

And then the fourth one is EHR integration, and we’ve talked about that in some detail. So those are the things that we know from a evidentiary point of view make a difference in A successful implementation of ICU liberation.

And then finally, if you know those are the the tools that you need in your toolbox, what are the barriers in front of you? So, four of those number one is staffing. It’s not just about the numbers. It’s about the quality and experience of the staff. And we’ve talked about that.

What, what, what I wanted to add to that discussion is that a lot of hospitals are hiring travelers. And these travelers, ironically, are very experienced and may have actually done ICU liberation, but they’re not institutionally invested. So they’re not working in your ICU for very long, and it’s hardly enough time to figure out how you operationalize ICU liberation, even if they wanted to do it on their best day.

So I think we need to move to a more stable staffing model. And I think eventually we’ll get there because frankly, travelers are very expensive. So it’s, it’s a win win win for the institution to hire permanent staff. And then the second barrier is competing quality improvement initiatives. So you go to the ICU.

And even if you’ve got a gung-ho C suite person that says, “We’ve got to do ICU liberation!, it saves $4.3 million over a five year period at the University of Wisconsin and 124. Bed ICU” – true fact.

And right, and, and so “We’ve got to do this!”– okay. “But oh, by the way, you’ve got the sepsis initiative, you’ve got the fall prevention thing going on, you’ve got CAUTI, you’ve got CLABSI, you’ve got VAI” —, and you’ve got a dashboard that covers an entire wall.

So I think that that’s again, where leadership plays an important role in helping ICUs to prioritize ICU liberation. So it’s closer to the top of that list of quality improvement initiatives.

Because guess what, folks? If you do ICU liberation, well, most of the other things on your dashboard are going to look greener, you’re not going to fall as much, you’re not going to have pressure ulcers as much you’re not going to have device related infections as much, or VAPs. Yeah. And so it’s just the moms apple pie of critical care medicine.

So I think ICU liberation needs to be at the top of that board, and also ran at the bottom. And then finally, staff burnout. And you’ve talked about this in your podcasts, and everybody is trying to wrack their brains like “Oh, my God, what are we going to do about burnout?”

Hello, ICU liberation, improves staff satisfaction. ICU liberation empowers staff, to take control of the care of the patient in front of them in a way that is meaningful, that they can see the impacts the positive impacts of their work. And it allows them to learn new things to learn new skills.

So people, to find joy in their work, have to feel a passion and a love for their work. I think people in healthcare, by definition, go into it because they want to help people. And they don’t want to hurt people. And so we need to not only tell ICU clinicians and providers of different stripes, that the old way of doing things is hurting people.

Because if you just stop there, you’ve just made them feel bad, and they’re not listening any longer…

Kali Dayton 1:03:37
and exacerbated the moral injury,

Dr. Juli Barr 1:03:39
Right! You need to say, “but the good news is, you have a choice. Here’s a different way of doing things, here are the tools to enable you to do it. We’re going to provide you with the education, we’re going to provide you with the training, we’re going to provide you with the infrastructure for you to be successful!”

And you know what? Burnout goes away. Now, there are other contributing factors to burnout. So I don’t want to oversimplify it here. But it goes a long way towards helping to address burnout in critical care medicine and EHR integration that is meaningful and efficient, so that clinicians aren’t just charting, charting, charting, and getting no return on investment for the time that they’ve entered.

All this stuff that is actually being used for purposes that they can see are helpful is also important. So there you have it, the secret sauce to successful implementation of ICU liberation.

Kali Dayton 1:04:35
I love it. I’m already thinking of multiple ICU revolutionist that I’m in contact with that are going to just eat this up. This is what we need to really be talking about. It’s the logistics of how to get there and what’s in our way. And everything you’ve shared, I think is really shared by many of us in ICU community.

I think revolutionists can feel very alone on their island trying to find the mainland and…. you’re not alone. So many people are faced In the same barriers, the same struggles. I really appreciate all the work that you’ve done throughout the years.

I know that it’s also been a very lonely, hard arduous road for you to fight and advocate for these practices to fight against the norm, the culture the standard. What last recommendations would you give to other icy revolutionists? Kind of what have you learned through your journey? And what what the personal obstacles that you face when trying to revolutionize this approach?

Dr. Juli Barr 1:05:32
I think I see revolutionists, as early adopters are the Johnny Appleseeds of ICU liberation, they are the people that are potentially pushing this message out and getting other people to want to follow them and spread this information and do this good work. And, and so you have to be a bit evangelical about it.

And by definition, they already have a passion around this, or they wouldn’t stick their necks out around this concept that seems so revolutionary at times, and it feels like you’re the only person but what I would say to them is this is that I think what you do with your podcasts, and what other people have done is that you’ve given a forum for these early adopters to learn from each other and what works and what doesn’t. So number one, that’s a key tool for them to be successful and not feel alone, that they have a community.

But it’s not just a session where people are complaining, they’re actually sharing best practices and solutions. So it’s okay to complain a little bit. But you can’t just bring a problem to other people, you have to bring a solution as well. So I think being able to share what’s worked, what hasn’t, and being brutally honest about that in a safe environment where they’re not going to be penalized for not being successful, that that something that you really bring to the table.

So thank you for doing that. I think the other lesson that I’ve learned is you need to meet people where they are, you know, the conversation that I have over lunch or in the doorway with another physician is fundamentally different than the conversation that I might have with a nurse at the bedside who just started working there last week. And he or she has never heard of ICU liberation, and they just look like a deer in headlights.

And it’s a fundamentally different conversation than what I have with the C suite person that I happen to run into in the elevator. And I’ve got exactly 30 seconds to literally give an elevator pitch. And it’s it’s easy to talk on and on and on about ICU liberation. But at the end of the day, you have to meet people where they are.

And you have to tailor your message to that person and figure out what’s important to them. And then find that connection between your passion around ice liberation, and their passion about the work that they do. And then you have something in common. And once you have something in common with someone, you build a rapport.

And once you build a rapport, you enhance your likability with that person. And once you have likeability and rapport, then you earn their trust. And then they’re more likely to go on that journey with you to that scary, dark, work intensive place that they just feel like they have no bandwidth or desire to pursue because they’ve got too much on their plate in front of them. So that’s my two cents.

Kali Dayton 1:08:41
I love it. And that I’ve seen that approach. And those that have had the most success. And I can testify that it works. And that it’s little by little those little things, those little steps, little interactions and communications over time, can make a huge impact. So I know I bring a big perspective into this podcast, if it’s the white walk in ICU, here’s what can and should be. Sometimes that can bring frustration, you know, impatience, but we’re all at different levels working towards the same goal and we can get there. And thank you for everything that you’ve done for being a disrupter for pushing the norm to a higher level. So thank you so much, Dr. Barr.

Dr. Juli Barr 1:09:22
Oh, thank you, Kali. And I hope this is the beginning of many conversations, because I’ve learned so much from you in a short period of time. And thank you for giving me this forum to talk to your audience.

Kali Dayton 1:09:33
I’m going to have you back on there’s a lot more to learn from you. Thank you. Okay, bye bye.

Transcribed by https://otter.ai

Citations

 

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https://pubmed.ncbi.nlm.nih.gov/36512684/
https://pubmed.ncbi.nlm.nih.gov/31818632/

1. https://daytonicuconsulting.com/walking-home-from-the-icu-podcast/walking-home-from-the-icu-episode-95-the-financial-cost-of-sedation-and-immobility/
2. https://pubmed.ncbi.nlm.nih.gov/35474653/
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