This repository provides the reproducible workflow for extracting A–F ICU Liberation Bundle elements from MIMIC-IV v3.1, including regular expressions, and a notebook that assembles the bundle cards. The goal is to make the identification logic transparent and portable across environments while adhering to data-use requirements.
If you use this work, please cite:
Islam MF, Douglas M, Mosier J, Subbian V. Standardizing Data Elements for Implementation of ICU Liberation Bundle. Applied Clinical Informatics. 2026;17(1):52-59. doi:10.1055/a-2802-7458
BibTeX
@article{10.1055/a-2802-7458,
title={Standardizing Data Elements for Implementation of ICU Liberation Bundle},
author={Islam, Md Fantacher and Douglas, Molly and Mosier, Jarrod and Subbian, Vignesh},
journal={Applied Clinical Informatics},
volume={17},
number={1},
pages={52-59},
year={2026},
doi={10.1055/a-2802-7458}
}| File | Description |
|---|---|
| A-F Liberation Bundle Cards.ipynb | Jupyter notebook implementing the end-to-end workflow: environment setup, BigQuery access, regex definitions, and SQL queries. |
| README.md | Project overview, setup instructions, and reproducibility notes. |
To reproduce results, you can either work locally with PhysioNet files or query the hosted copy in Google BigQuery. Both paths are outlined below.
After you complete the credentialed-access steps described under MIMIC-IV Data Source, you may download the dataset directly or via the command line. The example below mirrors the dialog shown in the PhysioNet file browser.
# Replace USERNAME with your PhysioNet username.
wget -r -N -c -np --user USERNAME --ask-password https://physionet.org/files/mimiciv/3.1/The bundle cards were evaluated using data and clinical scenarios derived from the MIMIC-IV.
Access: https://physionet.org/content/mimiciv/3.1/ (credentialed access required).
Bundle Card A - Assess, Prevent, and Manage Pain
Bundle Card B - Part I: Spontaneous Awakening Trials (SAT)
Bundle Card B - Part II: Spontaneous Breathing Trials (SBT)
Bundle Card C - Choice of Analgesia and Sedation (RASS)
Bundle Card D - Delirium: Assess, Prevent, and Manage (CAM-ICU)
Bundle Card E - Early Mobility and Exercise
Bundle Card F - Family Engagement and Empowerment
- Card Definition: A - Assessment, Prevention, and Management of Pain.
- Purpose: To observe the pain level, assign the pain score, and document a significant pain assessment.
- Critical Care Pain Observation Tool (CPOT) is a four-item scale - vocalization, body movements, facial expression, and muscle tension - each scored from 0 to 2.
- Alternative pain assessment tools: Numeric Pain Rating Scale (NRS), and Behavioral Pain Scale (BPS)
- Significant pain level is defined as CPOT > 2, or BPS > 5, or NRS > 3
- Conduct pain assessments at least 6 times within 24 hours to monitor compliance.
| Clinical Concept | Concept Values | Standardized Vocabulary: Code, Concept ID |
CDM Table |
|---|---|---|---|
| CPOT: Muscle Tension Score | 0: Relaxed 1: Tense, Rigid 2: Very tense or rigid |
OMOP Extension: OMOP5214828, ID: 722052 |
Measurement |
| CPOT: Vocalization Score | 0: No sound 1: Sighing, moaning 2: Crying out, groaning |
OMOP Extension: OMOP5214835, ID: 722060 |
Measurement |
| CPOT: Body Movements Score | 0: No movement 1: Protection 2: Restlessness |
OMOP Extension: OMOP5214824, ID: 722048 |
Measurement |
| CPOT: Facial Expression Score | 0: Relaxed, neutral 1: Tense 2: Grimacing |
OMOP Extension: OMOP5214820, ID: 722044 |
Measurement |
| CPOT: Total Score | Sum of scores from each of the four indicators | OMOP Extension: OMOP5214819, ID: 722043 |
Measurement |
| Clinical Concept | Concept Values | Standardized Vocabulary: Code, Concept ID | CDM Table |
|---|---|---|---|
| Numeric Pain Rating Scale (NRS) | Rate pain on a scale of 0 to 10 | SNOMED: 225398001, ID: 3715127 |
Measurement |
| Behavioral Pain Scale (BPS) | Facial expression, Upper limb movements, and compliance with mechanical ventilation | SNOMED: 273313008, ID: 3399022 |
Measurement |
- Card Definition: B: SAT - Spontaneous Awakening Trials.
- Purpose: To assess the ability to breathe without assistance by periodically stopping sedative drugs for mechanically ventilated patients.
- Assess whether the patient has received sedatives or opioid medications.
- Observe whether the sedative medium is continuous (IV-infusion) or intermittent (Bolus).
- Periodically stop or pause sedatives for mechanically intubated patients to help wean from ventilation.
- Record if patients were successfully weaned from mechanical ventilation during the trial.
| Clinical Concept | Concept Values | Standardized Vocabulary: Code, Concept ID |
CDM Table |
|---|---|---|---|
| Sedative | Midazolam, Propofol, Lorazepam, Dexmedetomidine, etc. |
SNOMED: 372614000, ID: 4156741 |
Drug |
| Sedative Route | • Continuously Infused • Intermittent/Bolus Scheduled • PRN ("as needed") |
SNOMED: 72641008, ID: 4219502 |
Procedure |
| SAT Assessment | Sedative Medication Stopped or Paused |
SNOMED: 424282004, ID: 4312631 |
Procedure |
| SAT Failure | • Anxiety, agitation, or pain • Respiratory rate > 35/min • Oxygen saturation < 88% • Respiratory distress • Acute cardiac arrhythmia |
SNOMED: 407563006, ID: 4253173 |
Observation |
- Card Definition: B: SBT - Spontaneous Breathing Trials.
- Purpose: To assess the ability to breathe without assistance by temporarily reducing or removing mechanical ventilatory support.
- Assess whether the patients are on mechanical ventilation modes, such as PSV, CPAP, or SPONT ventilation support.
- Start the SBT trial if the patient meets the criteria of Oxygen saturation ≥ 88%, FiO₂ ≤50% and PEEP ≤7.5 cmH₂O. Record the results if started or not.
- Reduce mechanical support, monitor the patient's ability to sustain independent breathing, and adjust ventilator settings such as PEEP and FiO₂ as needed to perform the SBT.
- Record the results if a patient completed the trial or documented the reason for the failure if different.
| Clinical Concept | Concept Values | Standardized Vocabulary: Code, Concept ID |
CDM Table |
|---|---|---|---|
| Ventilation Modes | • PSV: Pressure Support Ventilation • SPONT: Spontaneous • CPAP: Continuous Positive Airway Pressure • SIMV: Synchronized Intermittent Mandatory Ventilation • APRV: Airway Pressure Release Ventilation |
SNOMED: 1258885005, ID: 37158404 |
Procedure |
| SBT Started | Yes or No | LOINC: 93203-8, ID: 1001774 |
Observation |
| SBT Stopped | • RR > 35 for >5 min • Accessory Muscle Use • SpO₂ <90% for >2 min • BP >180 or <90 • HR >140 • Arrhythmia |
SNOMED: 407563006, ID: 4253173 |
Observation |
| SBT Completion | Yes or No | LOINC: 87542-7, ID: 36305814 |
Observation |
| SBT Deferred | • Unable to perform RSBI • Chronic vent dependent patient • Pending procedure • RSBI > 105 |
SNOMED: 416237000, ID: 4168192 |
Observation |
| RSBI: Rapid shallow breathing index |
- Card Definition: C - Choice of Analgesia and Sedation levels
- Purpose: To select appropriate sedation and analgesia levels
- Establish individual sedation level targets based on Richmond Agitation-Sedation Scale (RASS), a 10-point scale.
- Perform Arousal Assessments: Conduct arousal assessments at least 6 times within 24 hours to monitor compliance with the sedation targets.
- Continuously evaluate and adjust sedation and analgesia such as Fentanyl and Dexmedetomidine
- Record the results of each assessment, including those outside the sedation target
| Clinical Concept | Concept Values | Standardized Vocabulary: Code, Concept ID |
CDM Table |
|---|---|---|---|
| RASS Score | Ranges: +4 (Combative) to -5 (Unarousable) | SNOMED: 457441000124102, ID: 36684829 |
Measurement |
| Goal RASS Score | Ranges: 0 (Alert and Calm) to -2 (Light sedation). | SNOMED: 457441000124102, ID: 36684829 |
Measurement |
| Sedative Medications | See list below | RxNorm | Drug |
| Analgesic Medications | See list below | RxNorm | Drug |
| Sedatives | Analgesics |
|---|---|
| • Alprazolam • Amobarbital sodium • Ativan • Clonazepam • Dexmedetomidine • Diazepam • Ketamine • Lorazepam • Meprobamate • Midazolam • Pentobarbital • Phenobarbital • Propofol |
• Codeine Phosphate • Codeine sulfate • Fentanyl • Ketamine • Meperidine • Hydromorphone • Methadone • Mod-oxy-codone • Morphine • Oxycodone |
- Card Definition: D: Delirium: Assess, Prevent, and Manage
- Purpose: To assess delirium status from changes in consciousness, inattention, and mental status
- Administer the Confusion Assessment Method for the ICU (CAM-ICU)?
- Conduct delirium assessments at least 2 times within 24 hours to monitor compliance.
| Clinical Concept | Concept Values | Standardized Vocabulary: Code, Concept ID |
CDM Table |
|---|---|---|---|
| CAM-ICU RASS LOC | Yes or No | LOINC: 95857-9, ID: 36031363 |
Observation |
| CAM-ICU mental status Change | Yes or No | LOINC: 54632-5, ID: 40757763 |
Observation |
| CAM-ICU Inattention | • Yes (3 or more errors) • No (less than 3 errors) • Unable to Assess (UTA) • Language Barrier • Preexisting Advanced Dementia |
LOINC: 106402-1, ID: 1092114 |
Observation |
| CAM-ICU Altered LOC | Yes or No | LOINC: 95815-7, ID: 36031661 |
Observation |
| CAM-ICU Disorganized thinking | Yes or No or UTA | LOINC: 95814-0, ID: 36031539 |
Observation |
| Delirium Assessment Status | • Positive • Negative • UTA |
SNOMED: 733870009, ID: 37116854 |
Procedure |
- Card Definition: E - Early Mobility and Exercise
- Purpose: To encourage early physical activity to prevent muscle weakness and fasten the overall recovery.
- Evaluate the patient's mobility capabilities using exercises such as "Sit to Stand Ability" or "Transfer Ability".
- Document the results of each mobility or exercise
- After the initial evaluation, perform assessments for higher levels of exercise to further determine the patient's mobility range.
- Continuously observe and record the highest level of exercise or mobilization the patient achieves, noting any challenges or successes encountered.
| Clinical Concept | Concept Values | Standardized Vocabulary: Code, Concept ID |
CDM Table |
|---|---|---|---|
| Range of Motion (ROM) Status | • Passive • Active • min A (Minimal Assistance) |
SNOMED: 228528009, ID: 4036092 |
Procedure |
| Sit to Stand Ability | • mod A (Moderate Assistance) • max A (Maximum Assistance) • Contact guarding • Independent • Supervision |
LOINC: 89393-3, ID: 36306060 |
Observation |
| Activity / Mobility | • Lift to chair/bed • Turning in bed • Chair: Transfer to chair/bed • Stand: >/= One minute • Walk: 10+/25+/250+ Feet • Stand step • Stand pivot |
SNOMED: 363803005, ID: 4178501 |
Observation |
| Transfer Ability | • Contact guarding • Supervision • Squat pivot • Slide board • Independent |
LOINC: 83185-9, ID: 42529379 |
Observation |
- Card Definition: F - Family Engagement and Empowerment
- Purpose: To involve and engage families in the care process
- Record each instance of family visit, call, or communications with healthcare providers, including nurses and doctors.
- Hold family meetings to discuss the patient's care plan, ensuring consistent family involvement.
- Ensure that family decision-makers are informed about the ICU Liberation Bundle and the patient's care status.
- Allow and track family or friends participation in care rounds, noting their contribution to decision-making processes.
| Clinical Concept | Concept Values | Standardized Vocabulary: Code, Concept ID |
CDM Table |
|---|---|---|---|
| Family Communication | • Family Visited • Family Talked to Registered Nurse • Family Called • Family Talked to Doctor • Family Conference |
SNOMED: 14461000202103, ID: 1450126 |
Observation |
| Family Meeting | Yes or NO | SNOMED: 711070007, ID: 46272666 |
Observation |
| Family Informed | • Yes • No • Not Applicable |
SNOMED: 406141002, ID: 4247377 |
Observation |
For questions or collaboration inquiries, please contact:
Md Fantacher Islam
PhD Student, Systems and Industrial Engineering
University of Arizona
📧 fantacher@arizona.edu