to talk to you today about the current state of the ADF bundle in pediatrics. So you might think this talk's a little superfluous. Obviously the reason you're all sitting in this room is because you recognize there is a need for change with regards to how we do things in the ICU. But what I'd like to do is give you the lay of the land of where we're at right now. So I'm going to pause on this slide for a moment. You don't have to go searching for all of the literature on a daily basis that's directly relevant to PICU liberation. I wake up every morning. I have an exhaustive search that I've developed that incorporates every aspect of the ADF bundle that has anything to do with pediatrics and I add it to the list as relevant. So go to this list at any given day and you'll see what the most latest and greatest is in this area. So I see the cameras are up and they're going down. So definitely check that out. For example, the most recent pallic literature is all there already. So I want to make sure you guys all saw that. So I'm not going to focus on early mobility specifically here, but everything here comes down to illness doesn't mean stillness, right? We are taking care of kids during a formative time in their brain development. And I think you would all agree that everyone in the room, and some of you've heard me say this many times, would agree with this quote, that our ultimate goal is that we want children and their families to sustain the zest for living, which is a requirement for survival, right? And we don't always achieve that in the ICU the way they want. So where are we now? We need to understand that before we get to everything that my amazing colleagues are going to talk about, which is how do we get there and where do we want to be? So today I'm going to focus on this specific paper that is relatively hot off the press. It came out a few months ago with many of my amazing colleagues that are sitting in this room, looking at the ABCDF bundle practices across many different countries, 161 specifically in 18 countries. So here you can see these are the sites that were involved for us to collect this data, to help me give you the lay of the land of where we're at. So first of all, the reason that we did this survey is we wanted to understand from a liberation culture perspective, whether we at Hopkins were the only ones who needed to change our culture, and obviously the answer is no. So the first study that came out of the primary papers that came out of these is the PARCC-PICU study papers. This is the US, Canada and EU papers that were published. Dr. Colletti is the PI for the Brazilian study who's sitting up here in front that is going to be in press very shortly. So PARCC-PICU was a two day point prevalence study that is essentially evaluated what acute rehabilitation practices were for kids who are in the unit for greater than 72 hours. So obviously the kids that are at highest risk. And so, as you can see here, here's our US sites. And what we found was essentially we had a lot of work to do specifically in the mobility space. But one thing I really want to highlight, which is relevant to everything we're talking about in the bundle is 62% of the kids among these 1800 children on any given day in an ICU that were there longer than 72 hours were between the ages of zero and two. I mean, just take that in for a second. We are taking care of kids during the most critical time in their brain development and neurophysiologic development. And nurses and families, as you'll hear this theme over and over again, are the cornerstone of PICU liberation. And we found that they're already doing the work. We just need to give them the tools to be successful. So also early mobility was safe. That was something and I'm going to let my colleagues unpack that a bit more. So let's talk about practices across these 161 PICUs. So I'll pause on this for a moment. So I think there's some themes that you'll notice here. We're doing relatively well with regards to assessing pain, right? That's kind of the foundation and cornerstone of what we do as physicians. But how does that relate to the rest of the bundle elements? That's a question for you to ponder. In terms of spontaneous breathing and awakening trials, lots of variability there. Choice of sedation. This is specifically whether you're actually documenting sedation scores, not whether you're actually doing anything about them. Delirium monitoring, early mobility, big, big, big gaps here and lots of work to do there. We are awesome at family engagement for the most part. There's definitely gaps, but as you know, PEDS is one area where we do engage our families at the bedside much more than our adult critical care colleagues. Sorry if you're here. And then finally, ABCDF bundle, the full bundle. It's like you didn't even notice this over here, right? Cause it's so low. So what does it look like when we look at how people incorporate the different bundle elements? As you can see, there's really no theme here at all. So basically what we did is we looked at which units had which elements of the bundle and decided the proportion of that. So almost no one has incorporated the entire ABCDF bundle and everyone else has incorporated some permutation of the six bundle elements. So lots of variability in how we, in our units, have started to unpack and tackle this. So I won't spend too much time on pain because obviously we're doing a pretty good job with it. We do a great job with routine documentation and you can see that there's some variability here from a geographic perspective, but across the board, we have a lot of variability in the tools that we use. And the biggest variability is among the frequency of assessment and documentation. And variability is going to be the big theme for the next several. Another area where there is lots of work to do, essentially in terms of both SATs and SBTs, the vast majority of us are not routinely doing these. Some of us do have a protocol for ERTs. In terms of ventilator weaning protocols, only overall 34% of units said that they had those whether or not they utilize them regularly is again, a different story. And then who drives them, RT versus physician, et cetera. And I will just point out that this paper is also very hot off the press and I see Dr. Kamani there in the room. So please do check this out. All right, let's move on to choice of sedation. Where are we at with regards to our sedation documentation and monitoring? And hopefully this isn't the case. This is what we wanna move away from, right? It's not about our comfort. Here, we do a pretty darn good job of documenting the sedation scores. But the question is who's documenting them? And are we talking about them on rounds, right? So we document that the nurses are doing this amazingly because it's part of their, they have to do the documentation, but the translation is where we are likely having significant gaps. And you can see here in terms of the frequency, we're all over the board, two, four, other. And then we culturally and in different countries have different preferences for which sedation tools we use. And that's fine as long as they're validated. And fortunately, most of us are using validated pediatric sedation scoring tools. Sedation protocols, very variable there as well, about half of us have a sedation protocol that we utilize. Most of us do a pretty good job with assessing withdrawal and frequency of withdrawal and documentation is there. Delirium monitoring and management. This is a big area for us to work on. You're gonna hear a lot of awesome information about how to incorporate this. Only 44% of us say that we do routine screening of delirium documentation. Based on the countries that you're in, you use different screening tools. But luckily we have many tools that are validated within our populations and a decent job of assessing and documenting. And I'll just point out very quickly that in our recent study doing a secondary analysis, a positive or lacking delirium screening was the only independent risk factor for a mobility adverse event. So delirium has to be addressed. Early mobility, this is a big, big gap. Only 26% of us have any sort of protocol pertaining specifically to early mobilization and rehabilitation. And in terms of dedicated staff, you can see here 44% of us have a dedicated physical therapist. Very few of us have an occupational therapist. And given that we're habilitating infants and children, that's something for us to think about. And SLPs, also a significant gap. Family engagement. Family members can be at the bedside. We do a very good job with that. But how much do we actually engage the families on rounds? How much do we actually engage them in the activities that they are providing to their children? That's a different story. So are they given any sort of documents or training? Only 23% of units said they have anything that they can hand to families or talk to families about, about how they can engage with their child's care. So I'm not here to focus on implementation. You have fantastic colleagues who are gonna talk about it. But I'll just point out very quickly this realist review that was just published focusing on effective implementation in the ICU liberation bundle. Again, lots of hot off press literature. You can always go back to that QR code that you just took a picture of. It's all there. And the take homes from that study were essentially that we need a thorough understanding of the context. So I'm here to provide you the context that we have a lot of work to do. That's the take home there. So lots of room for improvement, guys. I have to say, I think you've identified that breathing, delirium, and early mobility are really, really low-hanging fruit for us to start to tackle. And again, it's not about sending one committee to work on delirium and other work to mobility. They go hand in hand. So we have to do this together as a bundle. Optimizing pain management before increasing sedation. We do an awesome job with pain assessment, but if we don't address pain first before we start snowing our pediatric patients, then we're really not making a lot of headway in terms of liberation. Consistency in sedation score and goal setting. We need to take the scores that our nurses are doing such an incredible job of documenting at the bedside and actually use that language to take care of our patients. If the SBS is a positive one or a positive two and the nurses documented that, we should not be, the nurse shouldn't be coming to us and saying, the kid's flying out of the bed. Will you give me something for sedation? But that's the culture that we, as physicians and APPs, have set up because we don't use those tools that they're documenting. And finally, multifaceted approaches, which is what you're going to learn about in the next several minutes. We are very excited that we have a 10 site pick you up trial that's ongoing. John Birkenbosch is in the back. He's one of the site PIs. I think there's a few other site PIs in the room, but there's a lot of work happening and you're also going to hear from my colleagues who are doing incredible work to look at implementation. Does it actually work? It might work at Hopkins, but does it work at other institutions if you do it the same way or differently? So lots to come and let's succeed together. Thank you very much.

ADF bundle

pediatrics

implementation

survey

collaboration