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ABCDEF Bundle Practices for Critically Ill Children: An International Survey of 161 PICUs in 18 Countries
Erwin Ista1, Juliana Redivo2, Paurav Kananur2
1Department of Pediatric Surgery, Intensive Care Unit, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands.
Insights
Pediatric intensive care units (PICUs) show varied adoption of the ABCDEF bundle for patient care. Further research is needed to assess the effectiveness of specific components and implementation strategies.
Area of Science:
- Pediatric critical care medicine
- Quality improvement initiatives
- Patient-centered care
Background:
- The ABCDEF bundle is a framework designed to improve care quality in pediatric intensive care units (PICUs).
- It encompasses six key components: Assessing Pain, Spontaneous Awakening and Breathing Trials, Choice of Sedation, Delirium Monitoring/Management, Early Exercise/Mobility, and Family Engagement/Empowerment.
- Understanding current international adoption rates is crucial for targeted quality improvement efforts.
Purpose of the Study:
- To evaluate the international adoption and implementation status of the ABCDEF bundle components in PICUs.
- To identify variations in practice across different geographic regions.
Main Methods:
- An online survey was administered to 161 PICUs across the United States, Canada, Brazil, and Europe between 2017 and 2019.
- Data were collected on the implementation of each of the six ABCDEF bundle components.
Main Results:
- Only 9% of surveyed PICUs had fully implemented all six ABCDEF bundle components.
- Standardized pain assessment (A) and family engagement (F) were most commonly reported (91% and 88%, respectively).
- Significant regional variations were observed, particularly in spontaneous breathing trials (B), delirium monitoring (D), and family engagement (F).
Conclusions:
- The adoption of the ABCDEF bundle components in PICUs is inconsistent across different regions.
- Further research is essential to evaluate the efficacy of individual components (B, D, E) and the full bundle.
- Implementation science is needed to address barriers and promote sustained adoption, considering regional and cultural differences.
Objectives:
To evaluate current international practice in PICUs regarding components of the "Assessing Pain, Both Spontaneous Awakening and Breathing Trials, Choice of Sedation, Delirium Monitoring/Management, Early Exercise/Mobility, and Family Engagement/Empowerment" (ABCDEF) bundle.
Design:
Online surveys conducted between 2017 and 2019.
Setting:
One-hundred sixty-one PICUs across the United States (n = 82), Canada (n = 14), Brazil (n = 27), and Europe (n = 38) participating in the Prevalence of Acute Rehabilitation for Kids in the PICU study.
Interventions:
None.
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.
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