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Table 3 A2F bundle [16] vs PICU LIBERATION bundle element specifics and measures (adapted from PUN et al. where able) [16]

From: Every child, every day, back to play: the PICUstars protocol - implementation of a nurse-led PICU liberation program

Bundle element

Adult A2F bundle



A – Optimising analgesia

PAD guidelines - pain assessments using a valid and reliable instrument

Institutional analgesia and sedation guidelines

• Stepwise introduction of analgesics first in agitated or distressed child

• Assessment of pain at least fourth hourly, using the FLACC score [26, 27].

Instances of

• FLACC assessments/opportunities

• Appropriate stepwise use of pain medication (percentage)

• WAT [28] assessments/opportunities

• Withdrawal instances

Opioid and benzodiazepine use

Instances of expressed breast milk and sucrose utilisation for procedural pain relief (number of prescriptions and administration episodes)

Empathic questionnaire results (carers' perception of child’s pain management)

B – spontaneous awakening and breathing trials

Guide for spontaneous awakening trial (SAT) if patients is receiving continuous or intermittent sedative infusions

Guide for spontaneous breathing trial (SBT) if receiving mechanical ventilation

• Safety screening tool and checklist for SABT adapted for PICU to guide nurse-led SABTs

• Safety screening tool and checklist for extubation readiness adapted for PICU to guide nurse enabled extubations

Instances of

• SABT screening performed/opportunities,

• SABT trials/opportunities,

• Extubation assessments/opportunity,

• Instances of nurse-enabled extubation/opportunity

• Ventilator associated pneumonia

• Failed extubations, accidental extubations requiring re-intubation within 1 h

• Delay from extubation ready to time of extubation

Hours/days without invasive ventilation

Empathic questionnaire results (carers' perception of child’s spontaneous awakening and breathing trials)

C – Choice of sedatives

PAD guidelines - agitation/sedation assessments using a valid and reliable instrument.

Institutional analgesia and sedation guidelines –

• Discourage use of sedatives, only second-tier treatment in the management of an agitated, ventilated patient; benzodiazepines, chloralhydrate and ketamine discouraged unless clinically indicated

• Assessment of sedation, agitation or arousal recommended at least fourth hourly, using the Richmond Agitation and sedation scale (RASS) [29]

Instances of

• RASS assessments/ opportunities

• Sedation goal set/ opportunities

• Sedation titration performed appropriately/ opportunities

• Number of patients with “deep sedation” (RASS > − 2)

• Instances of PTSS

• Medication side effects recorded (opioids, benzodiazepines, ketamine, chloral hydrate)

• Medication errors recorded


• Accidental line removal

Sedative use (by number of classes of sedatives used e.g., Benzodiazepines, chloralhydrate, ketamine)

Empathic questionnaire results (carers' perception of child’s sedation management)

D – Early assessment and management of delirium

PAD guidelines - delirium assessments using a valid and reliable instrument

Institutional delirium checklist and guideline –

• Guide to non-pharmacological (encouraged as first option) and pharmacological delirium management strategies.

• Delirium assessment recommended at least daily, using the CAP-D38

Instances of

• CAP-D assessments/opportunities,

• Delirium identified (instances),

• Appropriate management plan followed/opportunities (instances of non-pharmacological interventions targeting delirium, instances of pharmacological interventions targeting delirium)

• sleep adjuncts utilised (e.g. day/night routine; swaddling/nesting)

Empathic questionnaire results (carers' perception of child’s delirium prevention management)

E – Early mobility and rehabilitation

Guide to achieving mobility activities that were higher than active range of motion (i.e., dangling at edge of bed, standing at side of bed, walking to bedside chair, marching in place, walking in room or hall)

• A structured early mobilisation and rehabilitation program is commenced 24 h post admission to PICU. Children are classified into graded activity levels (Lizard, Koala, Wombat, Kangaroo) based upon the early mobilisation algorithm considering safety issues.

• Assessment of physical function is completed by a paediatric physiotherapist, using the Children’s Chelsea Critical Care Physical Assessment tool (cCPAx) [30]

Instances of

• Graded activity level goals set as daily goal,

• Instances of mobility level sign on patient’s door

• Mobility activities administered per patient per day

• Mobility levels achieved: Lizard – immobile, routine positioning and range of motion unless contraindications; Koala – in bed activities including sitting; Wombat – in bedspace activities including mobility out of bed/standing; Kangoroo – mobility out of bedspace including ambulatory*

• Falls


Deconditioning (assessment of physical function by instances of Children’s Chelsea Critical Care Physical Assessment tool (cCPAx)

Empathic questionnaire results (carers' perception of child’s mobility management)

F – Family engagement and empowerment

A family member/significant other was educated on the A2F bundle and/or participated in at least one of the following: rounds; conference; plan of care; or A2F bundle related care

Consumer information material educating family/carers on PICU Liberation bundle including goal setting and execution, family participation in cares, neurodevelopmental and early mobilisation activities and rounds

Instances of

• Tools used to ensure family inclusion (e.g. Daily goals chart updated with goals set, likes/dislikes on “getting to know you” form utilised),

• Family participation in liberation goal setting,

• Family participation in liberation goals activity (education provided on PICU liberation, cares, neurodevelopmental and early mobility activity, rounds, plan of care including baby liberation flower, instances of therapeutic cuddles, instances of trips outside the patient’s room)

• Family communication with healthcare providers “have you been kept up to date?”

• empathic questionnaire completion/opportunity

Number of Questionnaires administered to assess family coping and staff meaning making.

Empathic questionnaire results (carers' perception of engagement/inclusion/respect/care)

G – Good Nutrition

Not part of adult A2F

Institutional nutritional checklists - Anthropometric assessments (actual weights rather than estimated weights), nutritional assessments recommended at least weekly, patient specific nutritional goals set.

Paediatric growth charts completed.

Oral feeding readiness assessments

Instances of

• Patient weight assessment and weight estimates

• Nutritional goals set, instances of nutritional goals achieved

• Nutritional assessment tool used,

• Weight obtained, instances of appropriate nutrition delivered (defined as 2/3 of requirements reached enterally or parentally from 48 h post I/V), deconditioning, ICU related weakness, cognition.

• Nutrition free days.

Referrals to speech pathology

Oral feeding readiness assessments

Nutrition delivery routes i.e. nasogastric, parenteral

Empathic questionnaire results (carers' perception of child’s feeding and nutrition management)

H – Humanism

Not part of adult A2F

Institutional strategies to identify patients' and families' personal, developmental, and cultural preferences developed - family goals documentation recommended at least second daily.

Instances of

• Humanism goals set (inclduing photos printed and displayed at bedside, “getting to know you” form/careplan)

• Humanism goals achieved, instances of utilisation of tools to help personalise the patient for the clinicians (e.g. “getting to know you”),

• Individualised care/opportunity, number and results of questionnaires administered to measure meaning-making for staff and family coping (control charts).

• Family awareness of resources such as children’s book library, photo printing service (and use of same)

• Completion of “getting to know you” form

Empathic questionnaire results (carers' perception of individualised care; use of care planning etc)

Baby Liberation

Not part of adult A2F

Embedded in all PICU Liberation Bundle elements:

Institutional strategies to ensure infant neurodevelopment is optimised – Baby Liberation goals documented on “flower” depicting categories of care such as family engagement, use of breast milk for mouth cares, nesting and swaddling etc.

Instances of

Use of baby liberation flower use

Use of adjuncts such as “zaky” hands, nesting, swaddling, cuddles

Empathic questionnaire results (carers' perception of Baby Liberation programme)

Overall bundle performance

“Complete performance” defined as patient-day in which every eligible element of the bundle was performed (i.e., 100% of the bundle versus anything less)

“Proportional performance” defined as percentage of eligible elements a patient received on a given day (i.e., “bundle dose” in %)

Additional performance measures:

Target setting (Each morning Liberation targets including SP, RASS, mobility targets are to be set within the multidisciplinary ward round and documented in the PICU clinical information system)

Targets reached/adjusted: each afternoon during “check-ins”

Measurement of instances of performance of each bundle element per patient day (only measured if the patient was in PICU for a full 24 h from d3 of PICU stay)

Instances of daily goals set/opportunity.

Instances of Liberation check-ins completed/opportunity

Empathic questionnaire instances/opportunity

Empathic questionnaire results (carers' perception of Liberation program and individual elements)

  1. Mobility level examples: Lizard - routine positioning, range of motion activities; Koala - sitting in bed or on edge of bed, in bed cycling, other in bed mobility activities; Wombat - sitting out of bed, floor play, bed to chair transfers, short mobility activities, tilt table; Kangaroo - increased mobility activities around PICU and beyond, balcony visit, ride on toys