**8.3 Checklists and the checklist for early recognition and treatment of acute illness (CERTAIN) project**

Checklists have been recommended as decision support tools to decrease the number of cognitive errors [148] and to encourage reflective practice [79] and metacognition [149]. Using checklists within the acute care setting and the surgical suite has led to discovering latent threats to patient safety. Medical crisis checklists have been tested in a simulated environment, demonstrating improved management during a critical medical emergency [150].

CERTAIN has been implemented across more than 55 hospitals worldwide (https://www.icertain.org/partners). Physicians, nurses, and other allied health staff from these institutions use bedside decision support tools and web-based remote simulation and coaching. Utilizing quality improvement methodology, CERTAIN implementation has demonstrated feasibility and better adherence to critical care processes in a timely manner while decreasing complications, decreasing ICU LOS, decreasing hospital LOS, and lowering mortality [151]. Another advantage of CERTAIN is the ability to provide tele-education and coaching that leads to improved costs while also improving care and outcomes in resourcelimited ICUs [152].

#### **8.4 Bundles of care and the ICU liberation project (ABCDEF)**

Healthcare has shifted from the concept of caring for a critically ill patient from "ICU resuscitation and prolonged ICU stay" to an "ICU liberation" approach. The patient's outcome after an ICU stay has become a significant area of investigation, still requiring further understanding. In 2013, the Society of Critical Care Medicine and the American College of Critical Care Medicine joined forces to update the Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in the ICU adult (ICU PAD Guidelines) published in Critical Care Medicine [153], and soon after adopted the ABDCEF Bundle of Care for the ICU setting. This bundle includes: Assess, prevent, and manage pain; B consists of both spontaneous breathing trials and spontaneous awakening trials (SAT); Choice of analgesia and sedation; Delirium: Assess, prevent, and manage; Early mobility and exercise; and Family engagement and empowerment [154] and has been named the ICU Liberation ABCDEF Bundle.

In 2018, the implementation of the ABCDEF bundle of care in 68 adult hospitals resulted in decreased mechanical ventilation days, hospital deaths, incidence of delirium, and ICU readmissions. Collectively, using all the elements of this bundle, led to a significant dose-related improvement in the outcomes measured [155]. It is noteworthy that despite these improvements, ICU providers encounter challenges implementing all the elements of the bundle reliably and consistently [156] and questions remain unanswered, which will lead to further research [157].
