John Lin, MD
Program Director, PCCM Fellowship
Washington University School of Medicine
Saint Louis, MO
Disclosure information not submitted.
Avantika Srivastava, MS
Statistician
University of Pittsburgh, United States
Disclosure information not submitted.
Chani Traube, MD, FAAP, FCCM
Pediatric Intensivist, Clinical Researcher
NewYork Presbyterian Hospital
New York, New York, United States
Disclosure information not submitted.
Yu Kawai, MD
Assistant Professor of Pediatrics
Mayo Clinic, United States
Disclosure information not submitted.
Sapna Kudchadkar, MD, PhD, FCCM
Anesthesiology and Critical Care
Johns Hopkins University School of Medicine
Baltimore, MD
Disclosure information not submitted.
Christina Hielsberg, MA
Quality Program Manager
Society of Critical Care Medicine, United States
Disclosure information not submitted.
Vishakha Kumar, MD, MBA
Society of Critical Care Medicine
Mount Prospect, Illinois
Disclosure information not submitted.
Sara Aghamohammadi, MD
Assistant Professor of Pediatrics
UC Davis Children's Hospital, United States
Disclosure information not submitted.
Grace Arteaga, MD, FAAP,FCCM
Physician
Mayo Clinic, United States
Disclosure information not submitted.
Heidi Smith, MD, MSCI
Associate Professor Anesthesiology & Pediatrics
Monroe Carell Jr Children's Hospital at Vanderbilt
College Grove, Tennessee
Disclosure information not submitted.
Thomas Spentzas, MD, MS
Associate Professor of Pediatrics
University of Tennessee Le Bonheur Children's Hospital, United States
Disclosure information not submitted.
.jpg "Jerry Zimmerman, MD, PhD, FCCM photo")
Jerry Zimmerman, MD, PhD, FCCM
Faculty, Pediatric Critical Care Medicine
Seattle Children's Hospital
Seattle, Washington
Disclosure information not submitted.
Title: Caring for Critically Ill Children with the ABCDEF Bundle: the PICU Liberation Collaborative
Objective: To report PICU Liberation A-F Bundle implementation and outcomes.
Design: Prospective, multicenter, cohort study.
Setting: Eight academic, quaternary PICUs.
Patients: Children > 2 months with expected PICU stay > 2 days and need for invasive mechanical ventilation (MV).
Interventions: Following a 3-month baseline period, each site began an 8-month implementation period along with data collection of compliance and clinical outcomes.
MEASUREMENT AND MAIN
Results: 622 patients totaling 5017 PICU days were analyzed for Bundle compliance. 532 patients (4275 PICU days) with risk of mortality scores were analyzed for correlation between Bundle compliance and mortality, PICU LOS, duration of invasive MV, and delirium incidence. Bundle compliance was analyzed as both subject-specific (compliance over the entire PICU stay) and day-specific (compliance on a single PICU day). Overall subject-specific compliance increased from 50.2% during the 3-month baseline to 60.5% during the last four implementation months, p< 0.001. Subject-specific compliance for elements A and C did not change; compliance improved for elements B (21.4% to 27.0%, p=0.007), D (33.5% to 57.1%, p< 0.001), E (36.2% to 49.6%, p=0.003), and F (46.5% to 59.5%, p=0.001). On adjusted correlation analysis, every 10% increase in subject-specific compliance correlated with a 34% reduction in Odds Ratio for mortality (OR = 0.66, p< 0.001); every 10% increase in day-specific compliance correlated with a 1.4% reduction in mortality (OR=0.986, p=0.006). We observed no association between Bundle compliance and MV duration, PICU LOS, or delirium incidence. Relative Risk of delirium over the entire PICU stay was 1.09 (p< 0.001) for every additional day of invasive MV and OR of delirium on a given PICU day was 2.64 (p< 0.001) if MV was needed on the following day.
Conclusions: PICU Liberation and implementation of the A-F Bundle in critically ill children is feasible. Every 10% increase in bundle compliance over the entire PICU stay and on any one PICU day is associated with increased overall and next-day survival. Additional research is needed to better understand the association between individual element and overall Bundle compliance and clinical meaningful outcomes as well as comparative effectiveness studies examining A-F Bundle implementation strategies.