By Camille D. Ford | November 2025
Summary
Kelly Drumright and Dr. Matthew Mart are leading VA Tennessee Valley Healthcare System’s reimplementation of the ABCDEF ICU Liberation Bundle, transforming critical care by replacing deep sedation and immobility with wakefulness, early mobility, and family engagement. After achieving the nation’s highest performance in 2015-2017, the program collapsed during COVID-19 – and they’re rebuilding it to be indestructible. This time, they’re hardwiring the bundle into hospital infrastructure, creating automated performance dashboards, and training staff to overcome decades of harmful dogma. Their mission: ensure every veteran who survives the ICU returns not just alive, but cognitively intact, physically strong, and able to reclaim the life they had before.
Kelly Drumright remembers the moment that changed everything – not in a conference room or clinical training, but while watching her father die from metastatic colon cancer. Her mother clung to hope that he would recover, right up until his final breath. Drumright knew the truth. She had seen the radiology reports. She understood what metastatic cancer meant, but the medical team’s carefully worded explanations left her parents believing he just needed dialysis and more chemotherapy. The gap between medical reality and family understanding created what Drumright now calls moral injury – a harm that stays with you long after the patient is gone.
Dr. Matthew Mart’s transformative moment came early in his medical training. A younger woman with a devastating critical illness survived against the odds. She had children waiting at home. She desperately wanted to return to them, but weeks in the ICU had left her so weak and debilitated that going home was impossible. She needed extensive rehabilitation. She was readmitted multiple times. Her recovery stretched for months. Mart thought then what drives him now: we spend so much time saving lives, but wouldn’t it be great if we could get patients back to normal?
Together, Drumright and Mart are leading VA Tennessee Valley Healthcare System’s reimplementation of the ICU Liberation Bundle – a comprehensive approach to critical care that is transforming how veterans experience the ICU and what kind of life they return to afterward.
The First Wave: Excellence, Then Loss
The ABCDEF ICU Liberation Bundle first arrived at VA Tennessee Valley Healthcare System in 2014-2015 as part of an ambitious Society of Critical Care Medicine collaborative. Sixty-eight sites across the United States were implementing the same evidence-based approach, known by its acronym: The ABCDEF Bundle.
Each letter represents a practice element proven to improve outcomes:
- Assessing pain
- Both spontaneous awakening and breathing trials
- Choice of analgesia and sedation
- Delirium assessment
- Early mobility and exercise
- Family engagement and empowerment
The promise was powerful: getting critically ill patients out of the ICU sooner, stronger, and more cognitively intact. Less muscle wasting from prolonged bed rest. Less delirium and its devastating cognitive consequences. More humanity in the most inhumane circumstances imaginable.
VA Tennessee Valley Healthcare System didn’t just participate – they dominated. Of all 68 sites in that 2015-2017 collaborative, TVHS achieved the highest performance and compliance, demonstrating the best outcomes. They were number one.
Then came COVID-19.
The pandemic didn’t just disrupt the bundle – it obliterated it. Staff who championed the practices left or were reassigned. Bedside family rounds stopped. Deep sedation and paralysis returned as ICUs filled beyond capacity. The institutional knowledge that made TVHS number one simply vanished.
“COVID really changed everything for all of us,” Mart reflects. “Some of our best practices, like limiting sedation and getting people up and walking even if they need support on the ventilator, really fell to the wayside because we were so stretched thin. ICUs were full everywhere. There were medication shortages. We were dealing with so much.”
There was another problem that predated the pandemic: the bundle had never been fully integrated into hospital systems or standard policy. It lived in people’s heads, not in infrastructure. When those people left, the knowledge left with them.
Drumright saw this with brutal clarity. “At the end of 2017, we had not fully integrated these processes into the health record or into a standard policy. So, that was part of why it faltered during COVID – the people with the institutional knowledge to do this disappeared.”
Building Back Better: The Second Wave
Coming out of the pandemic, Drumright and Mart made a crucial decision. They wouldn’t just restore what was lost. They would build something sustainable – something that could survive staff turnover, future crises, and the inevitable churn of healthcare systems.
“We felt that we really needed to focus on implementing this because it had such positive outcomes on our patients and families,” Drumright explains. “But this time, we thought, why not do this in a way that could serve as a model for the entire VA system? This should be the standard of care across the world for critical care patients.”
The strategy had three pillars: hardwire the bundle into hospital infrastructure, make performance data visible and actionable, and train every single person who touches ICU patients.
Hardwiring Excellence
Drumright’s first priority was ensuring the bundle would survive even if she and every current staff member disappeared tomorrow. That meant embedding it into every system, every policy, every training protocol.
She’s creating standard operating procedures that will live permanently in the unit – detailed documentation of exactly how pain is assessed, how sedation awakening trials are conducted, how spontaneous breathing trials are coordinated, how delirium is monitored, how mobility is approached. Nursing competencies now include specific requirements for each bundle element.
Drumright went even further. When VA began transitioning to a new electronic health record system, she joined the design committee. Her mission: ensure that every ICU in the Department of Defense and VA system would have identical bundle content built into their electronic health record.
“When we all transition, every ICU will have the same bundle content,” Drumright explains. “We can all see how we’re doing comparatively across the nation.”
The goal is radical simplicity: making doing the bundle the path of least resistance. Build it so deeply into daily workflow that it becomes reflexive, automatic, invisible – the way things are simply done.
Making Data Visible
The second pillar involved partnering with VA’s Center of Innovation Network and VA Tennessee Valley Healthcare System’s Geriatric Research Education Clinical Center to create something the first implementation lacked: real-time, automated performance dashboards.
During the 2015-2017 implementation, tracking bundle compliance required absurd manual effort – extracting data from electronic health records, plugging numbers into spreadsheets, hiring statisticians to run analyses. It was unsustainable.
Now, dashboards show performance in near real-time. Physicians can see their individual compliance. Units can track month-to-month progress. Sites can compare performance across the entire VA system automatically with no manual data extraction.
“This is part of that ongoing continuous learning and improving environment,” Drumright emphasizes. “You need easily accessible, reliable data.”
Mart adds another dimension: leveraging Vanderbilt’s research infrastructure. “We’re attached by a tunnel to Vanderbilt University Medical Center, and many staff go back and forth. We utilize those research resources to help improve care here and at every other hospital in the country that provides ICU-level care.”
The partnership enables sophisticated analyses – identifying which interventions work best, understanding barriers to implementation, studying long-term outcomes in ways that weren’t possible before.
Training for Culture Change
The third pillar addresses the human element: changing deeply ingrained practices requires more than protocols. It requires shifting culture, confronting fears, and helping staff unlearn harmful habits masquerading as safety.
For decades, conventional ICU practice held that heavy sedation protected patients – kept them from remembering trauma, helped them rest and heal, and prevented dangerous agitation. Research proved this catastrophically wrong. Deep sedation causes profound harm: more delirium, worse cognitive outcomes, longer ventilator times, increased mortality.
Knowing intellectually that old practices were harmful doesn’t make them easy to abandon. Fear remains powerful.
“There’s fear,” Mart acknowledges. “Nurses, doctors, respiratory therapists – we want to help patients. You don’t want something to happen if you get your patient up out of bed and a line comes out or they have a fall. That fear is a barrier, and it’s not a wrong feeling to have, but we also have to be guided by the data that shows that actually, the dogma of ‘stay asleep, stay sedated’ actually hurts people.”
Drumright describes the challenge of convincing nurses trained entirely during COVID – nurses who had only ever seen deeply sedated, paralyzed patients – that a different approach was possible and better.
“They never saw what we were doing before,” she explains. “The idea that you can be on a ventilator and be awake and interactive and playing with your iPad, that concept was completely foreign to them.”
Overcoming that resistance requires demonstration, not just explanation. Show them it works. Do it with them. Let them see patients thriving with less sedation, walking while on ventilators, engaging with families.
“What it takes to overcome that hard mentality is: let me do this with you, watch me, let us show you,” Drumright says. “When Dr. Mart is on rounds or Dr. Ely is on rounds, they get in that room and show the interns, the residents, the nurses. They really talk about why this is important and help them understand that human connection.”
What Liberation Looks Like in Practice
Walk into morning ICU rounds at VA Tennessee Valley Healthcare System today, and you’ll witness something different from most hospitals.
The patient before the team requires mechanical ventilation, intravenous medications to support blood pressure, recent surgery, and pain management. A decade ago, this patient would have been deeply sedated, restrained, and immobilized. The family would have been in a waiting room.
Not today.
“You’d see teammates working together, and everybody on the team having a voice,” Drumright describes. “There’s a principle called ‘Deference to Expertise.’ You defer to whoever has the expertise in that specific situation. Sometimes that’s the nurse. Sometimes that’s the physician. Sometimes that’s the clerk. Sometimes it’s environmental management services. Sometimes it’s the engineer.”
Mart describes the structured approach: “We have a whole group of clinicians: physicians including myself and trainees, multiple nurses at the bedside, our pharmacist, respiratory therapists. We discussed how much sedation this person got overnight, how much pain medicine they received. Are we appropriately treating their pain? Are we giving too much?”
The goal, Mart tells his trainees is to make patients feel as normal as possible. Nothing about the hospital is normal like being on dialysis, on breathing machines, lying in bed with lights on 24/7. With that environment front of mind for the patient, the team works to restore normalcy: patients awake, alert, interacting with family, and moving when safe.
Pain vs. Sedation: The Critical Distinction
One of the most important skill shifts involves distinguishing pain from agitation and treating each appropriately.
“A lot of people just assume, ‘I’ve got to turn up the sedation,'” Drumright explains. “But do you realize they just had a really painful procedure? You don’t need to sedate them. You need to treat their pain.”
The stakes are high. When patients move or become agitated, reflexively increasing sedation may actually be depriving them of basic communication rights. They might be trying to say their arm itches or they need chapstick, and the response is holding them down, restraining them, sedating them further.
“That’s terrorizing,” Drumright says bluntly.
The Veteran-Specific Challenge
Veterans present unique considerations, particularly those with PTSD or complex PTSD from combat trauma.
“Overcoming sedation barriers, especially with veterans who have PTSD, requires getting nurses, interns, and residents to stop and think: What was this person’s behavior or mental health situation before they came in?” Drumright explains.
Often, talking with a spouse reveals crucial information such as what helps calm the veteran down, what triggers them, what music or activities bring comfort. That knowledge helps the team manage the transition as sedation is reduced, keeping the veteran oriented and calm rather than panicking.
Drumright acknowledges the fear this creates for nighttime nursing staff like caring for a combat veteran trained for violence, experiencing potential delirium, emerging from sedation. “That might terrify some nurses,” she says. “Without the training, understanding, and empathy to know we can get through this, it’s challenging.”
The solution involves the whole team. Pharmacists, physicians, nurses, and therapists working together, armed with knowledge about the specific veteran’s background and triggers.
The Data Behind the Vision
The reimplementation benefits from advanced research infrastructure, which was not available during the initial phase. Partnering with VA Tennessee Valley Healthcare System’s Geriatric Research Education and Clinical Center and VA’s Center of Innovation Network, the team has created automated dashboards showing bundle compliance in near real-time.
“We can look at dashboards almost in real time and provide data to physicians at an individual level,” Drumright explains. “We can see how everyone is doing month to month, site to site. This doesn’t require a lot of human power now that we’re automating it.”
The contrast with 2015 is stark. Back then, data collection required “an absurd amount of manual data extraction, plugging into Excel, hiring statisticians to do the numbers.” Now it’s automated, accessible, and actionable.
Mart emphasizes the research dimension: “We optimize research to try to understand questions we haven’t answered yet about the bundle, about the best way to do things, using our academic affiliation with Vanderbilt to leverage those research resources.”
Current research includes a forthcoming study on how rural veterans recover differently than urban counterparts after ICU stays – understanding unique needs and barriers across VA’s vast geographic footprint.
Deference to Expertise: Breaking Down Hierarchy
Perhaps the most profound culture shift isn’t about sedation or mobility – it’s about who gets to speak and be heard.
“There are respiratory therapists who are experts in procedures and equipment I can’t even pronounce,” Drumright says matter-of-factly. “There are engineers who understand handling units and requirements we have to meet. I don’t know all about that. That’s why we have them.”
The principle of “Deference to Expertise” means whoever has the relevant knowledge in a given situation gets deferred to, regardless of professional hierarchy. Sometimes that’s the physician. Sometimes it’s the nurse. Sometimes it’s the pharmacist.
“It’s having that team-based approach,” Drumright explains. “We’ve really focused on clinical team training so we’re all on the same page about where we’re going.”
Mart describes the interprofessional dynamic: “It’s not just doctors talking. It’s our nurses who give us details about vitals and their concerns and what they see going on. Our pharmacist talks about medicines and optimization. Our respiratory therapist tells us about breathing machine performance. It’s truly interdisciplinary, multidisciplinary, and family and patient-focused.”
That last part – family and patient-focused – represents another radical shift. Families aren’t visitors confined to waiting rooms. They’re present at rounds, asking questions, providing crucial context about the patient’s baseline function and wishes.
“Has the family been updated? Is the family at bedside? Can they join us while we’re rounding?” Mart asks during rounds. These aren’t rhetorical questions but rather they’re operational priorities.
The Hardest Barriers: Fear, Dogma, and Loss
Even with infrastructure, data, and training, significant barriers remain.
The first is fear. Clinicians worrying that mobilizing patients or reducing sedation will lead to adverse events. That fear isn’t irrational. ICU patients are fragile. Lines can dislodge. Falls can happen. The instinct to prevent harm through immobility and deep sedation is strong.
“Nurses and doctors and respiratory therapists, we want to help patients,” Mart says. “You don’t want something to happen. That fear is a barrier. But we have to be guided by the data that shows the dogma of ‘stay asleep, stay sedated’ actually hurts people. Leaning into that discomfort is one of the things we try to help overcome.”
The second barrier is challenging medical dogma. Telling esteemed providers that practices they’ve relied on for years are actually harmful based on new advancements and clinical research.
“Barriers are challenging these providers you’ve looked up to and respected,” Drumright explains. “Telling them we’ve actually been hurting patients. That things we said were good for them are not. Here, turn that sedation off. Here, take those restraints off. That’s hard when you’ve never seen it done before.”
The third barrier is institutional. Getting leadership to understand that ICU Liberation isn’t a side project or quality improvement initiative that can be done part-time. It requires dedicated resources, protected time, and organizational commitment.
“Over the past several years, every day has been a struggle and fight to explain why I need to keep doing this, because I’ve gotten pushback,” Drumright admits. “‘You can’t just do the bundle. This can’t be a full-time job.’ And I’m like, ‘Yes, it is. It’s not a project. It’s not a side gig. This takes a lot of manpower until it’s really ingrained in the infrastructure.'”
What Veterans Day Means to the Champions of Change
For Drumright, Veterans Day isn’t a single day of recognition – it’s a daily commitment.
“I think Veterans Day is a day of honor and taking a breath to remember,” she reflects. “We’re so busy in our work, in our lives, the chaos, the noise we pay attention to. Veterans Day gives us an opportunity to pause and remember that silence in the midst of the noise really matters.”
But more importantly, she wants every day to feel like it is Veterans Day. “I want to fight for what veterans need at the bedside and when they’re getting home every day. Every day is Veterans Day for me.”
That commitment comes from deep family connection. Drumright’s father served in the military. Though she didn’t serve herself, she feels called to serve those who did.
“I’m not here for the money. Money’s nice, but I want to do the right thing and demonstrate that you can do the right thing,” she emphasizes. “I want to show people they can take risks for what’s right. Because somebody has to be the change-maker. Somebody has to be willing to challenge things, even policy. Just because it’s policy doesn’t make it the right thing.”
Mart echoes the sentiment: “Our veterans have sacrificed something that I did not. If they can do that, how can I not offer my best in the care of them, advocating for the best care possible? That sacrifice didn’t happen on a single day. It happened with hundreds of thousands of men and women across centuries of U.S. history. How can I not come in and offer a small piece of myself in gratitude?”
He pauses, then adds: “For me, that’s the crux of what Veterans Day means, but it’s not relegated to just one day. Every day we show up and serve those who served. That’s a privilege.”
The Human Touch: Making Patients Normal
During rounds, Mart often asks trainees a question that catches them off guard: “Tell me about the patient. Who are they?”
Not their labs. Not their diagnosis. Who are they?
“What branch of service were they in? Where were they deployed? Are they married? Do they have kids? What do they like to do? Did they work?” Mart prompts. “These are the pieces that are really easy to lose in the hospital system. We’re focused on the numbers, the data, the medications. But at the heart of what we do, we meet people usually in one of the worst moments of their life. We’re trying to get them from point A to point B. The way we personalize and humanize that care is by understanding who that patient is.”
Sometimes the simplest interventions make the biggest difference. Mart describes patients who were delirious and struggling until someone brought their glasses from home, gave them a newspaper, and played their favorite music. The next day, clear.
“You have to be curious about the people you’re caring for,” Mart emphasizes. “If you’re not curious, you probably should do something else.”
Drumright shares a remarkable example of that philosophy in action: a full immersion baptism performed in the ICU for an elderly veteran whose last wish was to be baptized by his son, an ordained minister, in their faith tradition that required full immersion. The veteran was intubated on a ventilator.
“We had to get really creative quickly to honor that wish,” Drumright recalls. “Infection control people were like, ‘What did you do?’ But I think helping people find meaning in the work we do, especially during COVID when people were asking ‘Why are we doing this? People are dying,’ it’s about getting back to connecting with why we do this and helping people stay the humans that they are.”
Success Stories That Last
When the Society of Critical Care Medicine wanted to demonstrate the heart and soul of ICU Liberation to the international community, they created the ICU Hero Award – recognizing one pediatric and one adult patient each year whose story exemplifies what the bundle can achieve.
One of VA Tennessee Valley’s patients won that award.
He was a veteran facing acute respiratory failure so severe that lung transplant was being considered. To qualify for transplant, he needed to walk 200 feet. The problem? He required such high-level ventilator support that nurses and respiratory therapists were terrified to even move him.
“Normally, that’s not something any of us would have done,” Drumright recalls. “But he was awake enough, and we’ve got to do this. It’s that, or basically, you’re palliative. You’re hospice.”
He wanted to try. So, they got him up.
And he kept going.
Laps and laps around the unit. Every day, walking more. His lungs recovered completely. He went home. Not to a nursing facility for recovery, but straight home on a little bit of oxygen. Each day, he walked around his yard with his dogs.
He started coming back weekly to an ICU survivors support group VA Tennessee Valley Healthcare System offers for patients and families. Eight or nine years later, he still comes back. Once a year, bringing cake to the staff to celebrate another year of life.
“None of the original people are here anymore,” Drumright notes. “But he’ll still come back and do that.”
He’s also helped spread the message nationally, speaking at conferences about what it’s like to receive humanizing care in the ICU and why family involvement matters. He even wrote an article about his experience that was published, telling his story of how treating him like a soldier, giving him a mission and a goal to meet, gave him purpose and drive to push through.
“It was like, ‘Here, get out, you’ve got to do this thing,'” Drumright explains. “That challenge of exercising, meeting a goal. That’s what motivated him.”
The Vision for What Comes Next
Looking ahead, both Drumright and Mart have clear visions for how ICU care needs to evolve.
Drumright wants the bundle to become invisible. So integrated into standard practice that it’s no longer a “special initiative.”
“Should we even be calling it ICU Liberation 10 years from now?” she asks. “It should just be like a vital sign. There shouldn’t be, ‘Do you do the bundle?’ This should be how we care for patients. When we get to the point where this isn’t a special campaign but just the expectation, that’s when we’ve succeeded.”
Mart envisions continued research breakthroughs, particularly in understanding how rural veterans recover compared to urban counterparts – critical knowledge for a VA system serving veterans across vast geographic areas.
Both emphasize that this work is iterative, continuous, and never finished.
“This is an iterative process,” Mart stresses. “We get data that things are doing better, but we can always do better. We strive toward perfection. Rarely do we meet perfection, but we strive. And the data shows us where we need to improve.”
The Rebel and the Researcher: A Partnership for Change
Kelly Drumright, MSN, CNL, is a self-described rebel with a cause. Winner of the 2020 VA Secretary’s Award for Excellence in Nursing, the 2020 AACN Circle of Excellence Award, and the 2018 SCCM ICU Hero Award, she has spent 14 years in critical care refusing to accept that suffering is inevitable, that families must be kept at a distance, that deeply sedated patients represent good care.
She fights for policy changes even when it means challenging authority. She pushes boundaries finding creative solutions to honor human dignity even when protocols may not.
“I’ll take the blame for it,” she says matter-of-factly. “I’ll do that. I’m willing to take things further than what a newer staff member might do. I’m not here for the money. I want to do the right thing and demonstrate that you can do the right thing.”
Dr. Matthew Mart brings rigorous research to match Drumright’s passionate advocacy. As Assistant Professor of Medicine at Vanderbilt and physician at the Nashville VA’s Critical Illness, Brain Dysfunction, and Survivorship Center, his work on ICU survivorship – studying cognitive impairments, mechanisms of recovery, and rehabilitation strategies – provides the evidence base that makes sustainable change possible.
Together, they’re proving that transforming ICU care isn’t about choosing between compassionate nursing and evidence-based medicine, between individual patient stories and population-level data, between challenging the status quo and building sustainable systems.
It’s about doing all of it simultaneously. It’s about being willing to be uncomfortable, to challenge authority, to try things that haven’t been done before. It’s about curiosity, courage, and an unwavering commitment to the humans at the center of every medical decision.
A Culture of Excellence: Made, Not Found
“I’m just very proud of VA Tennessee Valley as a whole,” Drumright says. “I’ve seen some really excellent change and improvement over the past several years. It’s not because of one person or one group. It’s a culture thing. It’s a culture change. And we will continue to improve and get better.”
That culture change – from the first wave’s excellence, through COVID’s devastation, to the current reimplementation with infrastructure and sustainability built in – represents something larger than ICU Liberation.
It represents what’s possible when dedicated clinicians refuse to accept that the way things have always been done is the way things must always be done. When they challenge medical dogma backed by decades of tradition. When they build systems designed to survive beyond any individual champion.
The revolution is not complete. Every day brings new challenges, new opportunities, new patients who need what ICU Liberation promises: a chance not just to survive the ICU, but to return to the life they had before.
For Kelly Drumright and Dr. Matthew Mart, that is not just professional work. It is personal mission. It is daily commitment. It is the reason they keep fighting, keep innovating, keep pushing toward a future where every veteran who enters the ICU at VA Tennessee Valley Healthcare System has the best possible chance not just to live, but to thrive.
At VA Tennessee Valley Healthcare System, liberation is not just a bundle. It is a belief. And for Kelly Drumright and Dr. Matthew Mart, that belief is lived every day at the bedside.
Resources for Veterans and Healthcare Professionals
ICU Liberation and Critical Care Information
- Society of Critical Care Medicine ICU Liberation: ICU Liberation | SCCM
- ICU Delirium and Cognitive Impairment Study Group: ICU Delirium
VA Healthcare and Patient Care Services
- VA Health Care Enrollment: How To Apply For VA Health Care | Veterans Affairs
- My HealtheVet: Home – My HealtheVet – My HealtheVet (Manage VA healthcare, prescriptions, and appointments)
- Veterans Crisis Line: Dial 988, then press 1 | Text 838255 | Veterans Crisis Line
Critical Care and ICU Survivorship
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center: Vanderbilt University Medical Center Vanderbilt University Medical Center | Vanderbilt Health Nashville, TN
- Post-Intensive Care Syndrome (PICS) Resources: Post-Intensive Care Syndrome (PICS)
- American Association of Critical-Care Nurses: American Association of Critical-Care Nurses – AACN
Tennessee Valley Healthcare System
- TVHS Main Site: VA Tennessee Valley Health Care | Veterans Affairs Nashville VA Medical Center: 1310 24th Avenue South, Nashville, TN 37212
About the Subjects
Kelly Drumright, MSN, CNL, CCRN-CMC, CSC, is a Clinical Nurse Leader at VA Tennessee Valley Healthcare System with 14 years of critical care nursing experience. She is the 2020 winner of the VA Secretary’s Award for Excellence in Nursing, 2020 AACN Circle of Excellence Award, and 2018 SCCM ICU Hero Award. Her unit received the AACN Silver Beacon Award from 2017-2020.
Matthew Mart, MD, is Assistant Professor of Medicine in the Division of Allergy, Pulmonary and Critical Care Medicine at Vanderbilt University Medical Center and physician at the Nashville VA’s Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center. His research focuses on ICU survivorship, cognitive impairments after critical illness, and rehabilitation strategies.
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