Caring for Critically Ill Children With the ICU Liberation Bundle (ABCDEF): Results of the Pediatric Collaborative*

Abstract

OBJECTIVES: Assess clinical outcomes following PICU Liberation ABCDEF Bundle utilization. DESIGN: Prospective, multicenter, cohort study. SETTING: Eight academic PICUs. PATIENTS: Children greater than 2 months with expected PICU stay greater than 2 days and need for mechanical ventilation (MV). INTERVENTIONS: ABCDEF Bundle implementation. MEASUREMENT AND MAIN RESULTS: Over an 11-month period (3-mo baseline, 8-mo implementation), Bundle utilization was measured for 622 patients totaling 5,017 PICU days. Risk of mortality was quantified for 532 patients (4,275 PICU days) for correlation between Bundle utilization and MV duration, PICU length of stay (LOS), delirium incidence, and mortality. Utilization was analyzed as subject-specific (entire PICU stay) and day-specific (single PICU day). Median overall subject-specific utilization increased from 50% during the 3-month baseline to 63.9% during the last four implementation months (p < 0.001). Subject-specific utilization for elements A and C did not change; utilization improved for B (0–12.5%; p = 0.007), D (22.2–61.1%; p < 0.001), E (17.7–50%; p = 0.003), and F (50–79.2%; p = 0.001). We observed no association between Bundle utilization and MV duration, PICU LOS, or delirium incidence. In contrast, on adjusted analysis, every 10% increase in subject-specific utilization correlated with mortality odds ratio (OR) reduction of 34%, p < 0.001; every 10% increase in day-specific utilization correlated with a mortality OR reduction of 1.4% (p = 0.006). CONCLUSIONS: ABCDEF Bundle is applicable to children. Although enhanced Bundle utilization correlated with decreased mortality, increased utilization did not correlate with duration of MV, PICU LOS, or delirium incidence. Additional research in the domains of comparative effectiveness, implementation science, and human factors engineering is required to understand this clinical inconsistency and optimize PICU Liberation concept integration into clinical practice.

Moving Away From Randomized Controlled Trials to Hybrid Implementation Studies for Complex Interventions in the PICU*

“…The study by Choong et al (5) focused on assessing the adherence to bundle utilization in ventilated pediatric patients. While they did note an increased utilization of the bundle, they did not find any associations with mechanical ventilation duration, PICU length of stay, or the presence of delirium, in contrast to findings in adult patients (14, 15). Unexpectedly, upon conducting adjusted analyses, enhanced bundle utilization correlated with a decreased probability of death.…”

“…A study conducted in adult ICUs has revealed that the complete implementation of the ABCDEF bundle is linked to improved survival rates, as well as reduced durations of mechanical ventilation, delirium, and coma (13). Recently, the results of a multicenter study on the clinical outcomes following the application of the Pediatric ABCDEF bundle were published (14). The study by Choong et al (5) focused on assessing the adherence to bundle utilization in ventilated pediatric patients.…”

Post-PICU Cognitive and Psychological Outcomes in Children Receiving Treatments for Acute Lymphoblastic Leukemia

“…The unexpected lack of significant differences between the groups may also be attributed, in part, to the rehabilitation/early mobility program and implementation of the ABCDEF Bundle (37–39) as well as strong psychosocial and behavioral health services provided to patients within this institution. In 2022, the PICU Core Outcome Measurement Set forth core measures to study PICU outcomes to facilitate continued research for post-PICU patients and survivors, including cognitive, emotional, and social health (40).…”

Barriers to Implementing the ICU Liberation Bundle in a Single-center Pediatric and Cardiac ICUs

“…7 In a multicenter study of 622 high-risk pediatric ICU (PICU) patients, a concerted Pediatric ICU Liberation implementation effort modestly improved ABCDEF Bundle element adoption from 50% to 64% over an 8-month period. 8 Unfortunately, this increase was not sufficient to be associated with improved MV duration, delirium, or ICU length of stay. An international survey of 161 PICUs in 18 countries reports that ABCDEF Bundle components have been variably adopted worldwide.…”

“…Seattle Children's Hospital (SCH) was one of eight pediatric institutions that participated in the PICU Liberation implementation study. 8 As part of that work, we developed and conducted a PICU staff survey study to understand what barriers were perceived or experienced in implementing ABCDEF Bundle elements. We conducted this survey in 2017 and again in 2020, and used staff responses to identify the most common barriers, examine changes in barrier perception over time, and examine differences in barrier perception by role, to inform our local implementation efforts.…”