ABCDEF Bundle Practices for Critically Ill Children: An International Survey of 161 PICUs in 18 Countries*

Abstract

MEASUREMENTS AND MAIN RESULTS:Of the 161 participating PICUs, 83% were in academic teaching hospitals and 42% were in free-standing children's hospitals. Median size was 16 beds (interquartile range, 10-24 beds). Only 15 PICUs (9%) had incorporated all six ABCDEF bundle components into routine practice. Standardized pain assessment (A) was the most common (91%), followed by family engagement (F, 88%) and routine sedation assessment (C) with validated scales (84%). Protocols for testing extubation readiness or conducting spontaneous breathing trials (B) were reported in 57%, with 34% reporting a ventilator weaning protocol. Routine delirium monitoring with a validated screening tool (D) was reported by 44% of PICUs, and 26% had a guideline, protocol, or policy for early exercise/mobility (E). Practices for spontaneous breathing trials were variable in 29% of Canadian PICUs versus greater than 50% in the other regions. Delirium monitoring was lowest in Brazilian PICUs (18%) versus greater than 40% in other regions, and family engagement was reported in 55% of European PICUs versus greater than 90% in other regions. CONCLUSIONS: ABCDEF bundle components have been adopted with substantial variability across regions. Additional research must rigorously evaluate the efficacy of specific elements with a focus on B, D, E, and full ABCDEF bundle implementation. Implementation science is needed to facilitate an understanding of the barriers to ABCDEF implementation and sustainability with a focus on specific cultural and regional differences.

Ventilation Liberation Practices Among 380 International PICUs

“…In addition, the sedation assessment and delirium elements of the ICU liberation bundle were more commonly present than the ERT and early mobility elements. Although these findings are consistent with recent international practice data, our study adds a more in-depth understanding of international practice relevant to pediatric ventilation liberation and the "B" bundle element (21). These results reinforce an opportunity to standardize pediatric ventilation practices in an effort to eliminate noise and discriminate strategies that drive outcomes.…”

Modified ABCDEF-Bundles for Critically Ill Pediatric Patients - What Could They Look Like?

“…For children, a recent survey showed an implementation of all aspects in only 9% of 161 PICUs in the US, Canada, Brazil and Europe ( 19 ). Although there are calls for implementation of these measures in pediatric intensive care, as with most medical developments, the use of adult therapies in children without crucial changes beyond adaptation for size and body weight has not been effective ( 18 ).…”

“…In 2019, Arroyo-Nonoa et al ( 41 ) found only 8 works on IWS in adult critical care patients, with two published between 1998 and 2016 and 6 between 2017 and 2019. In contrast, this is one aspect where pediatric research is more advanced, having introduced and validated scoring tools for early detection ( 42 , 43 ), after showing it to lead to relevant stress for both patients and parents ( 19 ). Additionally, IWS has been shown to be an independent risk factor for development of delirium, which in turn factors heavily within the long-term effects of critical care treatment (see bundle D below).…”

“…Even before the current pandemic led to restrictions in visitation all over the world, 24-h-attendence was made possible in about 88% of PICUs considering hospitals in the US, Canada, Brazil and Europe. Unfortunately, in Europe less than half of PICUs reported permitted 24 h presence by family members ( 19 ).…”

“…While literature shows a solid scientific foundation for adult patients, implementation in PICUs is lacking ( 19 ). Interestingly, within this field of study there are more reviews available than clinical studies ( 72 ).…”