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

Crit Care Med. 2022 Jan 1;50(1):114-125. doi: 10.1097/CCM.0000000000005168.


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.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Anesthesia / standards
  • Clinical Protocols
  • Critical Illness / therapy*
  • Delirium / diagnosis
  • Delirium / prevention & control
  • Delirium / therapy
  • Family
  • Humans
  • Intensive Care Units, Pediatric / standards
  • Intensive Care Units, Pediatric / statistics & numerical data*
  • Pain Measurement / standards
  • Pain Measurement / statistics & numerical data
  • Patient Care Bundles / standards
  • Patient Care Bundles / statistics & numerical data*
  • Ventilator Weaning / standards