Implementing ICU Liberation Bundle benefits mechanically ventilated patients

Key takeaways:

• Use of the ICU Liberation Bundle was linked to shorter ICU stays, less time on ventilation and fewer patients in the ICU for 7 days or longer.
• Compliance with bundle elements was partial across hospitals.

Among mechanically ventilated patients, implementation of the ICU Liberation Bundle meant shorter ICU stays and less time receiving ventilation, according to study results published in Critical Care Explorations.

Findings from this study were also presented at this year’s Society of Critical Care Medicine’s Critical Care Congress.

“This is now the third large multicenter study demonstrating significant improvements in ICU patient outcomes following bundle implementation,” Juliana Barr, MD, FCCM, staff anesthesiologist and intensivist at VA Palo Alto Health Care System, said during her presentation. “But unlike previous studies, this study quantified the cumulative impacts of the bundle on ICU patient outcomes and demonstrated successful spread and sustainability of the bundle across a large health care system outside of a one-time quality improvement project.”

In a multicenter, prospective cohort observational study, Barr and colleagues assessed 1,914 adult ICU patients receiving mechanical ventilation at six hospitals in the Dignity Health System to determine the impact of ICU Liberation Bundle use on patient outcomes.

Researchers also sought to evaluate bundle sustainability and spread, so they included 9,717 adult ICU patients receiving mechanical ventilation from 28 hospitals within the same health care system.

Notably, the ICU Liberation Bundle is also known as the ABCDEF Bundle, with each letter standing for a different element of care, according to Barr:

• “Assess, prevent and manage pain;
• Both spontaneous awakening trials (SAT) and spontaneous breathing trials (SBT);
• Choice of analgesia and sedation;
• Delirium: Assess, prevent and manage;
• Early mobility and exercise; and
• Family engagement and empowerment.”

To determine if use of the bundle changed patient outcomes, researchers compared data taken within a 12-month period before bundle implementation (baseline) with data taken within a 12-month period following implementation.

Patient outcomes

Of the cohort of mechanically ventilated patients in six hospitals, 925 had baseline data and 989 had bundle performance data.

Compared with patients who received care prior to ICU Liberation Bundle implementation, those who received care after bundle implementation had significantly shorter ICU stays (5.09 days vs. 5.55 days; P = .02), spent less time on mechanical ventilation (4.35 days vs. 4.94 days; P = .01) and had a smaller percentage of patients with an ICU stay of 7 days or longer (23.1% vs. 38.2%; P < .01).

Hospitalization duration and mortality rate did not significantly differ between the two groups.

In a cohort of ICU patients who did not receive mechanical ventilation (baseline, n = 1,323; performance, n = 1,696), Barr said they did not find significant improvement in any of the studied outcomes.

Compliance

In another assessment of the mechanically ventilated cohort, researchers looked at data from the 3 months prior to bundle implementation vs. data from the 12-month bundle implementation period to evaluate changes in compliance for each individual element of the ICU Liberation Bundle.

Pain management compliance, SAT/SBT compliance, reintubation rates (part of bundle element B) and family engagement stayed the same between the two periods, whereas metrics in bundle elements C and D changed over time.

During both periods, pain assessment and SAT/SBT compliance was high, and reintubation rates stayed low.

In bundle element C, researchers observed a significant rise in sedation assessments (P < .01), as well as a significant drop in benzodiazepine sedation use (P < .01) between the two periods. In terms of delirium, or bundle element D, Barr said assessments of this mental state significantly increased (P = .02) and prevalence significantly decreased (P = .02).

Of the two metrics within bundle element E, one significantly decreased (routine mobility assessments; P = .03), whereas the other stayed the same (percentage of patients with a mobility score of 2 or higher) between the two time periods.

Sustainability, spread

Following completion of this part of the study, researchers went back 3 years later to reassess bundle compliance in the same six hospitals (n = 2,332 receiving mechanical ventilation).

Several bundle elements remained the same as before: benzodiazepine use (low), sedation and delirium monitoring (high), patient mobility (low) and family engagement (low).

Notably, during the reassessment, researchers found that SAT compliance fell from 86% to 45% and SBT compliance fell from 92% to 53%.

“The lower compliance rates in the study for SAT and SBT trials, early mobility efforts and family engagement may reflect the greater need for interprofessional team communication, collaboration and care coordination to execute these particular bundle elements,” Barr said during her presentation.

When comparing bundle compliance from these hospitals with compliance from the 28 hospitals not included in the initial study, Barr said compliance was “generally higher” in the 28 hospitals across several bundle elements, including daily SAT (46.1% vs. 44.5%), daily SBT (58.2% vs. 53.2%), sedation and delirium monitoring (86.4 vs. 83.1%), patient mobility (36.5% vs. 28%) and family engagement (60.5% vs. 56.7%).

“Even partial bundle performance significantly improves patient outcomes and reduces health care costs,” Barr said. “Yet many hospitals and health care systems have yet to fully implement the A through F bundle, citing staffing shortages, EHR limitations and costs. ICU providers and leaders must partner with hospital and health care system executives to make the business case for ICU liberation.”

Reference:

• Barr J. Thought leader: Late-breaking studies affecting patient outcomes I. Presented at: Society of Critical Care Medicine’s Critical Care Congress; Jan. 21-23, 2024; Phoenix.