Standardizing Data Elements for Implementation of ICU Liberation Bundle

Abstract

Background

Getting patients out of intensive care units (ICUs) is a major goal for acute care clinicians, as prolonged stays increase the risk of complications and strain critical resources such as staff, equipment, and beds. The ICU Liberation Bundle, or the ABCDEF (A-F) care bundle, is an evidence-based framework for improving outcomes in critically ill patients by addressing pain, sedation, delirium, mobility, and family engagement. However, variability in documentation and a lack of standardized data elements hinder effective implementation and evaluation of adherence to bundle components.

Objectives

This study aims to characterize data elements of the A-F liberation bundle using a large, single-center critical care database and to develop standardized bundle cards that map bundle components to controlled vocabularies.

Methods

We conducted a retrospective analysis of data elements related to the A-F bundle using the MIMIC-IV database. Clinical concepts were mapped to standardized vocabularies and aligned with the Observational Medical Outcomes Partnership (OMOP) common data model (CDM). Bundle cards were developed for each component to provide structured, accessible documentation of assessment tools, adherence criteria, and terminology mappings.

Results

Pain assessments were documented in over 11,000 patients, with a median of 23 assessments per day. Sedation levels for nearly 59,000 patients were evaluated, with 37.7% meeting the Society of Critical Care Medicine (SCCM) adherence criteria. Delirium assessments followed standardized protocols incorporating Richmond Agitation-Sedation Scale (RASS) and CAM-ICU scores. Components E and F lacked formal compliance specifications; bundle cards for these components identified key activities and highlighted gaps in standardized vocabularies. Adherence analyses revealed variability likely due to non-standardized documentation practices.

Conclusion

We developed and validated six ICU Liberation Bundle cards that map bundle components to standardized vocabularies and CDMs, enabling retrospective adherence evaluation in real-world data. These information resources promote consistent documentation, support interoperability, and provide a foundation for prospective monitoring to enhance bundle implementation in critical care.

Keywords

ICU Liberation Bundle - ABCDEF bundle - controlled vocabulary - OMOP common data model - standards - clinical data management - data processing - ontology

Protection of Human and Animal Subjects

Human subjects were not included in the project.

Data Availability Statement

The bundle cards and code with regular expressions required to reproduce the results are available at: https://github.com/vsubbian/Bundle-Cards.

Publication History

Received: 28 July 2025

Accepted: 02 February 2026

Accepted Manuscript online:
03 February 2026

Article published online:
12 February 2026

• References

• 1 Borgert MJ, Goossens A, Dongelmans DA. What are effective strategies for the implementation of care bundles on ICUs?: A systematic review. Implement Sci 2015; 10 (01) 119
• 2 van Gelder TG, van Diem-Zaal IJ, Dijkstra-Kersten SMA, de Mul N, Lalmohamed A, Slooter AJC. The risk of delirium after sedation with propofol or midazolam in intensive care unit patients. Br J Clin Pharmacol 2024; 90 (06) 1471-1479
• 3 Trogrlić Z, van der Jagt M, Bakker J. et al. A systematic review of implementation strategies for assessment, prevention, and management of ICU delirium and their effect on clinical outcomes. Crit Care 2015; 19 (01) 157
• 4 Paul N, Ribet Buse E, Knauthe AC, Nothacker M, Weiss B, Spies CD. Effect of ICU care bundles on long-term patient-relevant outcomes: A scoping review. BMJ Open 2023; 13 (02) e070962
• 5 Nates JL, Nunnally M, Kleinpell R. et al. ICU admission, discharge, and triage guidelines: A framework to enhance clinical operations, development of institutional policies, and further research. Crit Care Med 2016; 44 (08) 1553-1602
• 6 Marra A, Ely EW, Pandharipande PP, Patel MB. The ABCDEF Bundle in critical care. Crit Care Clin 2017; 33 (02) 225-243
• 7 Martin B, Mulhern B, Majors M. et al. Improving pediatric intensive care unit discharge timeliness of infants with bronchiolitis using clinical decision support. Appl Clin Inform 2023; 14 (02) 392-399
• 8 Mion LC, Tan A, Brockman A. et al. An exploration of critical care professionals' strategies to enhance daily implementation of the assess, prevent, and manage pain; both spontaneous awakening and breathing trials; choice of analgesia and sedation; delirium assess, prevent, and manage; early mobility and exercise; and family engagement and empowerment: A group concept mapping study. Crit Care Explor 2023; 5 (03) e0872
• 9 DistilINFO Provider. ICU Care Best Practices Available on Epic, Cerner EHR software. Accessed November 24, 2024 at: https://www.distilnfo.com/provider/2020/02/14/icu-care-best-practices-available-on-epic-cerner-ehr-software/
• 10 Hobbins A. ICU Liberation Bundle: Nursing Attitudes and Potential Barriers to Implementation [MS dissertation]. Providence, RI: Rhode Island College; 2023
• 11 Walz A, Canter MO, Betters K. The ICU Liberation Bundle and strategies for implementation in pediatrics. Curr Pediatr Rep 2020; 8 (03) 69-78
• 12 Morandi A, Piva S, Ely EW. et al. Worldwide survey of the “Assessing Pain, Both Spontaneous Awakening and Breathing Trials, Choice of Drugs, Delirium Monitoring/Management, Early Exercise/Mobility, and Family Empowerment” (ABCDEF) Bundle. Crit Care Med 2017; 45 (11) e1111-e1122
• 13 McCudden A, Valdivia HR, Di Gennaro JL, Berika L, Zimmerman J, Dervan LA. Barriers to implementing the ICU Liberation Bundle in a single-center pediatric and cardiac ICUs. J Intensive Care Med 2023; 39: 558-566
• 14 Lynch KE, Deppen SA, DuVall SL. et al. Incrementally transforming electronic medical records into the observational medical outcomes partnership common data model: A multidimensional quality assurance approach. Appl Clin Inform 2019; 10 (05) 794-803
• 15 Hallinan CM, Ward R, Hart GK. et al. Seamless EMR data access: Integrated governance, digital health and the OMOP-CDM. BMJ Health Care Inform 2024; 31 (01) e100953
• 16 Crisan A, Drouhard M, Vig J, Rajani N. Interactive Model Cards: A Human-Centered Approach to Model Documentation. Paper presented at: 2022 ACM Conference on Fairness, Accountability, and Transparency. ACM; 2022
• 17 Zhu J, Cukier M, Richardson Jr J. Nutrition facts, drug facts, and model facts: putting AI ethics into practice in gun violence research. J Am Med Inform Assoc 2024; 31 (10) 2414-2421
• 18 Johnson AEW, Bulgarelli L, Shen L. et al. MIMIC-IV, a freely accessible electronic health record dataset. Sci Data 2023; 10 (01) 1
• 19 Athena. Observational Health Data Sciences and Informatics (OHDSI). Accessed December 7, 2025 at: https://athena.ohdsi.org/search-terms/start/
• 20 Mitchell M, Wu S, Zaldivar A. et al. Model Cards for Model Reporting. Paper presented at: Proceedings of the Conference on Fairness, Accountability, and Transparency.. ACM; 2019 :pp. 220-229
• 21 Pushkarna M, Zaldivar A, Kjartansson O. Data Cards: Purposeful and Transparent Dataset Documentation for Responsible AI. Paper presented at: 2022 ACM Conference on Fairness, Accountability, and Transparency. ACM; 2022
• 22 Guenther U, Popp J, Koecher L. et al. Validity and reliability of the CAM-ICU Flowsheet to diagnose delirium in surgical ICU patients. J Crit Care 2010; 25 (01) 144-151
• 23 Scott P, Thomson P, Shepherd A. Families of patients in ICU: A scoping review of their needs and satisfaction with care. Nurs Open 2019; 6 (03) 698-712
• 24 White DB, Angus DC, Shields AM. et al; PARTNER Investigators. A randomized trial of a family-support intervention in intensive care units. N Engl J Med 2018; 378 (25) 2365-2375
• 25 Davis CL, Bjoring M, Hursh J. et al. The Intensive Care Unit Bundle Board: A novel real-time data visualization tool to improve maintenance care for invasive catheters. Appl Clin Inform 2023; 14 (05) 892-902