ICU Liberation

When you think of a hospital intensive care unit, you probably envision bedridden, highly sedated patients breathing with the assistance of a ventilator and connected to a maze of tubes. But at Parkland Memorial Hospital in Dallas, that picture is changing

A new quality improvement project at Parkland called “ICU Liberation” hopes to free intensive care patients from serious, often permanent declines in physical and cognitive function resulting from the intensive care experience. The 18-month initiative sponsored by The Society of Critical Care Medicine selected 77 U.S. intensive care units to participate in the “A-F Bundle Improvement Collaborative” aimed at eliminating negative outcomes resulting from ICU care. The Parkland Surgical Intensive Care Unit (SICU) is one of only two ICUs in Texas selected to participate.

“This project has the potential to revolutionize ICU care and save lives,” said Brian Williams, MD, assistant professor of surgery in the Division of Burn/Trauma/Critical Care at The University of Texas Southwestern Medical Center, who leads the A-F Bundle project at Parkland

PostIntensive Care Syndrome

Every year 5.7 million people are admitted to ICUs in the U.S. for life-saving care. Thanks to advances in critical care medicine, most recover, but nearly one-half of these patients end up with permanent impairments in their physical, mental or psychiatric health due to Post-Intensive Care Syndrome, or PICS. PICS can cause serious, irreversible health problems including muscle weakness, cognitive or brain dysfunction, loss of memory, depression, severe anxiety, and even PTSD symptoms.

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“Pain, agitation, delirium, immobility and interruption of normal day-night cycles have been considered ‘normal’ for ICU patients. Actually, they all contribute to PICS. These are not normal or healthy and we need to eliminate them in ICU settings,” Williams said. early mobility in ICU

From left to right: Alicia Stafford, PT; patient; Emily Beffa, PT; Ashley Bruner, RN; Steve Spratlen, RT. Photo courtesy of Parkland Health and Hospitals System.

The A-F Bundle project focuses on the following aspects of ICU care to minimize PICS:

  • A – Assess, prevent and manage pain
  • B – Both Spontaneous Awakening Trials (SAT) and Spontaneous Breathing Trials (SBT)
  • C – Choice of analgesia and sedation
  • D – Delirium: assess, prevent and manage
  • E – Early mobility and exercise
  • F – Family engagement and empowerment Parkland’s multidisciplinary SICU team includes critical care physicians and nurses, respiratory therapists and physical, occupational and speech therapists, among others

Transforming ICU Care

All disciplines are collaboratively engaged in transforming ICU care to meet the goals of the A-F Bundle project. Williams decided to place the greatest emphasis at the beginning of the project on the Early Mobility (E) bundle. “Until very recently, no one in the SICU would have dreamed of trying to get an intubated patient (one whose breathing is assisted by a ventilator) walking,” said Emily Beffa, a physical therapist. “Now it’s becoming routine at Parkland. We start small, getting the patient to sit on the edge of the bed, then stand and move to a chair. Using a portable ventilator, we assist the intubated patient to walk in the hallway – a pretty impressive feat that has a big impact on everyone who sees it.”

Anastacio (Andy) Garcia, 48, a North Texas truck driver, took a giant step toward recovery on March 14 when he felt sunshine on his skin for the first time in many weeks. With the help of a portable ventilator and SICU staff members, Garcia enjoyed an hour in the warm spring air in Parkland’s Wellness Garden.

Admitted to Parkland’s SICU on February 12, Garcia has been treated for necrotizing fasciitis, a serious skin infection. Unable to speak due to the tracheostomy tube and ventilator that helped him breathe, he also was showing symptoms of deepening depression, according to his wife Glenda and Parkland staff. Going outdoors noticeably lifted his spirits, Glenda said. “I feel like he turned a corner then. It’s not just physical therapy – it’s also mental health therapy to be outside the room, moving, and in a new setting. It really brightened his mood.”

Best Interests of Patients

“Mobility is the pinnacle – it’s the most visible change in how ICU patients are managed, so that’s why we’re so focused now on the Early Mobility and Exercise bundle,” said Natalie Provenzale, RN, quality improvement ,manager at Parkland. “Getting more patients up and walking is a huge change from what happens in a typical ICU and it’s a big culture change for the SICU staff at Parkland.”

Stacey Barker, RN, SICU Associate Unit Manager, says the E bundle gets family members more engaged in their loved one’s care and gives them a greater sense of control and hope. It also helps nurses think beyond the here-and-now, she said. “Nurses are trained to focus on providing pain relief and comfort measures. But the ICU Liberation project is teaching us to consider what’s in the best interest of the patient in the long run, not just in the moment.”

For Beffa, the project represents a holistic approach to ICU care. “ICUs are the new frontier in physical therapy,” she said. “Historically, patients have spent many days in the ICU before a physical therapist is called in to work with them. By then they are weak, have lost balance and are often depressed. At Parkland, all that has changed. Now our perspective is that patients should be mobile if at all possible to help them get better faster and avoid future health complications.”

Tina Damas, RN, an ICU nurse at Parkland who serves as the “nurse champion” for the Early Mobility bundle, said more than 1,200 patients are admitted to Parkland’s SICU each year and all will receive the full benefit of this project. “I am passionate about the ICU Liberation initiative because we are saving lives and avoiding preventable disabilities with this project. It makes my job as a nurse so much more gratifying, even though it’s requiring us to change,” Damas said.

To learn more about the ICU Liberation A-F Bundles project, visit

Natalie Provenzale is quality improvement manager at Parkland Memorial Hospital.

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