ICU liberation: Optimizing quality and efficiency of critical care delivery

Providing “health” care is expensive, and providing “sick” care is even more expensive. Here we will outline a newly packaged, high-yield opportunity for your institution regarding optimization of your critical care service line that sparked the efforts of the Society of Critical Care Medicine to improve care delivery and patient outcomes.

As of 2015, the National Health Expenditure accounted for 17.8% of the Gross Domestic Product, which equated to $3.2 trillion, and per capita expense of $9,990. Projected expenditures for 2016-2025 show NHE growth of 5.6% per year and per capita expense growth of 4.7% per year.1 As such, policymakers at the Federal and State level are feverishly working at least to slow the costs of care, and at best to decrease the costs of care. Large scale policy and funding has shifted towards integrated care systems, bundled payments, and driving care towards a less hospital-centric venue. This paradigm shift is now becoming part and parcel of the logistics and economics of providing quality healthcare within the United States.

With the increased focus on value-based payments, providers of all sizes and types have moved to identify ways to reduce costs while improving efficiency, quality, patient safety, and outcomes. The question is whether this can realistically be achieved. The opportunity to accomplish these goals could be great if we focus on the 20 medical conditions that consistently account for ~50% of aggregate hospitals costs for all payors and 45% of hospital stays.2 Perhaps even more important is that failure to recognize and manage many of those same medical conditions will result in an eventual admission to the intensive care unit where costs are 2.5 times greater than those of non-ICU admissions. Indeed, over 1 in 3 health care dollars is spent on ICU-related charges.3 Therefore, it is no surprise that payors of all types are focused on limiting the necessity of such high levels of care for their covered lives. Herein lies the dilemma: can healthcare providers and administrators maximize efficiency and reduce costs (i.e. decrease ICU and hospital length of stay) without compromising quality and patient safety of that level of care?

One way to maximize the efficiency of care, reduce costs, improve quality, and optimize the safety of care associated with ICU services is described by Dr. E. Wesley Ely in his February 2017 article and plenary given in Hawaii at the SCCM international convention, “The ABCDEF Bundle: Science and Philosophy of How ICU Liberation Serves Patients and Families.”4 Dr. Ely describes the post-intensive care syndrome, a well-known chronic and debilitating health condition following critical illness characterized by acquired post-ICU dementia and physical and psychological impairments. The ICU Liberation Collaborative (, an initiative supported by the SCCM and sponsored by the Gordon and Betty Moore Foundation of Palo Alto, launched in 2014 to support the implementation of the ABCDEF bundle, a care paradigm that improves survival and reduces both brain dysfunction and time on expensive life-support such as mechanical ventilation.

Based on the SCCM’s evidence-based guidelines for management of Pain, Agitation, and Delirium, the ABCDEF bundle was created ( from hundreds of peer-reviewed investigations including over 30 from the New England Journal of Medicine, Lancet, and JAMA. These targeted strategies focus on appropriately assessing and managing a patient’s pain and sedation needs, assessing their ability to come off of a ventilator with daily spontaneous awakening and breathing trials, identifying and reducing the risk of delirium, implementing early mobility to prevent muscle weakness, and addressing the psychosocial needs of the patient and family through compassionate, patient-centered care.

All of this is performed utilizing a collaborative inter-professional team approach that includes nurses, physicians, respiratory therapists, pharmacists, physical and occupation therapists, social workers, and chaplains. Successful implementation incorporates the science behind the medical management of the patient with active engagement of both the patient and family in care delivery, thereby benefiting physical recovery and psychological well-being.5

Of the 76 total hospitals that took part in the ICU Liberation Collaborative nation-wide, each institution has their own tale to tell about how they overcame barriers to changing behavior while implementing the interconnected components of the ABCDEF Bundle. As this important work has spread and become adopted, other healthcare systems are reporting associated positive outcomes. In one healthcare system in California, the authors reported that within their 7 community hospitals, in a study of over 6,000 patients that adjusted for severity of illness and age, they found a 15% higher odds of survival for every 10% improvement in overall bundle compliance by the ICU teams. They also reported a similar increase in the number of days alive without delirium or coma (and thus able to have meaningful interactions with their family and loved ones).7,8

Pediatric patients are also being included in this ‘game changing’ quality improvement work as infants and children also experience profound negative long-term outcomes associated with critical illness and consume immense resources both during and following ICU stays. As with adult ICU experiences, the pediatric ICU environment is associated with prolonged exposure to sedatives while on mechanical ventilation, immobility, lack of caregiver presence, and experience of pain, anxiety, and delirium.9 Sedation during critical illness has previously been shown to be a significant risk factor for delirium in adults. This past fall 2017, high benzodiazepine exposure (such as midazolam) was reported by Smith and colleagues in Critical Care Medicine to be an independent predictor of increased likelihood and duration of delirium and associated with a longer ICU length of stay among infants and preschool-aged children.10 Not surprisingly, pediatric delirium during critical illness not only prolongs ICU stay, but also increases healthcare costs.11 The ongoing Pediatric ICU Liberation Collaborative includes PICUs at 8 prominent institutions demonstrating that comprehensive changes in clinical practice can be successful using a foundation of inter-professional collaboration, caregiver engagement and presence, and incorporation of patients’ physical, spiritual, and psychosocial health.

Administrators have a crucial opportunity to facilitate and support this essential work. Due to variability in resources, capabilities, and competing priorities, launching successful initiatives can be fastidious work for clinicians that often result in issues with buy-in and long-term sustainability. Administrative support from the onset of program implementation is essential in setting the stage for goal prioritization and efficient resource utilization in an ever-changing healthcare environment. Providing excellence in clinical care is not cheap; however, healthcare leaders must strive to become better stewards of our available resources. We must be open and willing to institute unique processes that support evidence-based medicine and empower frontline faculty and staff to ensure those processes are successful.

As administrators, we are often told that additional FTEs are required to implement changes effectively. In a resource-strapped environment, additional resources are often not an option. This, however should not be the reason for failure to launch. Acknowledging the aforementioned capital and FTE constraints, the ABCDEF bundle allows for flexibility to match available resources to the patient’s needs in a much more cost-conscious manner. The ICU Liberation Collaborative Institutions found that adding additional resources was often not necessary if they followed a model of close inter-professional collaboration, mindful attention to current resource allocation, using innovation in the creation and utilization of standardized tools and communication, and reviewing current methods to identify potential opportunities for waste reduction.

While policymakers and healthcare financiers are looking to improve the value of care purchased, innovations like the ICU Liberation Collaborative provide a roadmap of not only delivering such care in a location that is well-known for its high cost of care, but also aims to decrease the sequelae of such care via reductions in the toll that PICS takes on both patients and their families. Through such innovations, the hope and strategy is to arrive at the goals of the Triple Aim, which is to decrease the per capita costs of care while improving the patient experience of care as well as the health of entire populations.6 With ICU Liberation and the ABCDEF bundle, the return on investment for your patients, their families, and your institution may be your highest yield yet.

Ajoy Kumar, MD, FAAFP
Chief Medical Officer
Bayfront Health St. Petersburg
St. Petersburg, Florida
Dr. Ajoy Kumar is currently the Chief Medical Officer of Bayfront Health St. Petersburg, Florida, current President of the Florida Academy of Family Physicians, and the Immediate Past-President of the Southern Medical Association. He is involved in healthcare policy development at the local, state, and national levels through several medical associations.

Erika Gabbard, DNP, RN, CCNS, CCRN
Director, Critical Care Network
Pulmonary and Critical Care
Carolinas HealthCare System
Charlotte, North Carolina
Dr. Erika Gabbard is currently the Director of the Critical Care Network at the Carolinas HealthCare System. Her passion for critical care and advancing nursing practice keeps her busy as a CCRN® and ACLS instructor, President for Piedmont Carolinas Chapter of AACN, and new member of the CCNS® Exam Development Committee for the national AACN organization.

Heidi AB Smith, MD, MSCI
Assistant Professor
Department of Anesthesiology & Pediatrics
Division of Pediatric Cardiac Anesthesia
Vanderbilt University
Monroe Carell Jr. Children's Hospital at Vanderbilt

Jennifer Vedral-Baron, MN, APRN, NP-C, FAANP, FACHE
U.S. Department of Veterans Affairs
Health System Director
Tennessee Valley Healthcare System
Nashville Campus
Nashville, Tennessee

J. Matthew Aldrich, MD
Medical Director, Critical Care Medicine
Associate Clinical Professor
Anesthesia and Perioperative Care
University of California—San Francisco

E. Wesley Ely, MD, MPH
Professor, Grant W. Liddle Endowed Chair in Medicine
Pulmonary and Critical Care
Veteran’s Affairs Geriatric Research Education Clinical Center (GRECC)
Vanderbilt University Medical Center, Nashville, TN

4. Ely, EW. The ABCDEF Bundle: Science and Philosophy of How ICU Liberation Serves Patients and Families, Critical Care Medicine, 2017 45(2): 321-330.
7. Hunter, A., Johnson, L., & Coustasse, A. (2014). Reduction of intensive care unit length of stay: The case of early mobilization. The Health Care Manager, 33(2), 128-135.
8. Barnes-Daly MA, Phillips G, and Ely, EW. (2015) Implementing PAD Guidelines via the ABCDEF Bundle at 7 California Community Hospitals: a 15-month interprofessional team experience in more than 6,000 patients. Critical Care Medicine. 43(12). p 11.
9. Smith HAB., Berutti T., Brink E., Strohler B., Fuchs DC., Ely EW., Pandharipande PP. Pediatric Critical Care Perceptions on Analgesia, Sedation, and Delirium. Semin Respir Crit Care Med 2013;34(2);244-61.
10. Smith HA, Gangopadhyay M, Goben CM, et al. Delirium and Benzodiazepines Associated With Prolonged ICU Stay in Critically Ill Infants and Young Children. Crit Care Med 2017;45(9):1427-1585.
11. Traube C, Mauer EA, Gerber LM, et al. Cost Associated With Pediatric Delirium in the ICU. Crit Care Med. 2016 Dec;44(12):e1175-e1179.

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