The ABCDEF Bundle: Science and Philosophy of How ICU Liberation Serves Patients and Families

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 Post-Intensive Care Syndrome (PICS). Patients with PICS 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 (QI) 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 implementation of the Pain, Agitation, and Delirium (PAD) 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 so doing, patients are liberated from iatrogenic aspects of care that threaten her or his sense of self-worth and human dignity. The goal of this 2017 plenary lecture at the 47th SCCM 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, QI program is novel, generalizable, and practice-changing.

The 2014 updated version of the Confusion Assessment Method for the Intensive Care Unit compared to the 5th version of the Diagnostic and Statistical Manual of Mental Disorders and other current methods used by intensivists

“…This is paramount for treating the factors associated with delirium [ 6 , 27 – 35 ] as soon as possible, especially when taking into account the negative outcomes associated with delirium [ 5 , 6 ]. A comprehensive approach [ 48 ] integrating delirium management with analgesia, sedation, mechanical ventilation, mobility/exercise and family engagement/empowerment has shown a positive impact on increasing ventilatory-free days [ 49 , 50 ], decreasing delirium incidence [ 49 – 51 ] and improving hospital mortality [ 51 ].…”

Multicenter assessment of sedation and delirium practices in the intensive care units in Poland - is this common practice in Eastern Europe?

“…This indicates that more education and a change of culture is warranted. ICU Liberation concepts can become part of the “new way” of patient management, and this was a focus of the SCCM’s ICU Liberation Collaborative for the past two years in the US [ 26 ]. Indeed, even easy to use tools and mnemonics for how to respond clinically when a patient is diagnosed with delirium can be taught and incorporated into daily ICU care (e.g., the Dr. DRE mnemonic – D isease r emediation, D rug R emoval, E nvironmental modifications).…”

Assessment of the Safety of Discharging Select Patients Directly Home From the Intensive Care Unit

“…Assessments of the Safety of Discharging Select Patients Directly Home From the Intensive Care Unit life support technologies to include transitions of care to help patients, family caregivers, and clinicians prepare for patient discharge. 38 Second, select patients should be eligible to be discharged directly home. The potential benefits include shortening hospital lengths of stay, reducing transitions of care, decreasing flow failure, and alleviating ICU capacity strain.…”