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

John C. Lin, Avantika Srivastava, Sara Malone, Susan Jennison, Megan Simino, Chani Traube, Kimberly Larose, Yu Kawai, Lori Neu, Sapna Kudchadkar, Beth Wieczorek, Krista Hajnik, Christina M. Kordik, Vishakha K. Kumar, Sara Aghamohammadi, Grace M. Arteaga, Heidi A.B. Smith, Thomas Spentzas, Andrea Orman, Becky Mc Gee LandmanHector Valdivia, Heather Browne, Timothy Fang, Jerry J. Zimmerman

Research output: Contribution to journalArticlepeer-review

12 Scopus citations


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.

Original languageEnglish
Pages (from-to)636-651
Number of pages16
JournalPediatric Critical Care Medicine
Issue number8
StatePublished - Aug 1 2023


  • Bundle
  • delirium
  • intensive care unit liberation
  • pediatric critical care


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