© Hong Kong Academy of Medicine. CC BY-NC-ND 4.0
 
COMMENTARY
ICU Liberation for critically ill children in Hong Kong
A Dudi, MB, BS, FAAP1; KL Hon, MB, BS, MD1; Henry CH Pak, MSc, BSc PT2 Stephen WW Chan, DHSc, MSc2; Cecilia YS Leung, MSc, BSc OT2; Sabina CS Chan, MSc, MA2 CC Au, MB, BS, MRCPCH1
1 Paediatrics and Adolescent Medicine, Hong Kong Children’s Hospital, Hong Kong
2 Department of Allied Health, Hong Kong Children’s Hospital, Hong Kong
 
Corresponding author: Dr CC Au (aucc@ymail.com)
 
 Full paper in PDF
 
Intensive care unit (ICU) Liberation (https://www.sccm.org/iculiberation) is a campaign to promote patient recovery by being mindful of reducing iatrogenic harms during ICU stay, proposed by the United States Society of Critical Care Medicine.1 2 The ICU Liberation bundle includes the ABCDEF elements (Box). The ICU Liberation elements have been broadly adopted in adult intensive care units and improved outcomes significantly.3 Moreover, ICU Liberation could be adapted to the needs of children and their family.4 5 Herein we present our own experience of adopting and implementing ICU Liberation practices at a paediatric ICU (PICU) in Hong Kong.
 

Box. Intensive care unit Liberation bundle
 
In the past decade, more patients have survived paediatric intensive care compared with previous decades.6 This has brought long-term morbidities among patients discharged from the PICU, collectively known as post–intensive care syndrome (PICS) in children.7 8 These long-term morbidities include functional deficits of physical, cognitive, emotional, and social health that affect the daily life, school performance, and social performance of these patients and their family.9 10 11 The PICS affects one-third of patients discharged from PICU and can persist for years.12 The well-intended and often aggressive treatment in the PICU is, in part, the origin of PICS in children. The PICU stay is a physically traumatic and emotionally stressful experience for children and their family, and these individuals may develop PICS, such as post-traumatic stress disorder13 or critical illness myopathy.14 Acute PICU care prioritise disease control with aggressive treatment over considerations for sleep, recovery, and rehabilitation; however, the patient may develop ventilator dependence,15 physical impairment,16 or delirium.17 18
 
The PICU at Hong Kong Children’s Hospital commenced service on 27 March 2019. In the first 2 years, the capacity of the PICU grew rapidly from four beds to 16 beds, with a total of 650 patients treated. The PICU provides a full range of intensive care support, including mechanical ventilation, continuous renal replacement therapy, and extracorporeal life support. As clinical leaders with a vision to transform PICU culture in our hospital, we advocate ICU Liberation in our daily practice. We have established close collaboration between medical, nursing, and allied health teams. The PICU practice has evolved according to consensus and teamwork.
 
Our practice is founded on a humanistic approach. Learning, caring, and smiling are the core values of the Hong Kong Children’s Hospital. Education is emphasised to consolidate knowledge and changes. Individual patient care goals are regularly discussed by staff during team rounds. Staff also receive formal on-the-job training as well as informal feedback, including on pain assessment, non-pharmacological treatment, and analgesics; spontaneous awakening and breathing trial in children; sedation titration to target adequate effect; environmental modification to promote sleep and reduce delirium; early mobilisation; and family empowerment. A clinical information system is used to document and review individual patient progress in the ABCDEF elements. Patient outcomes are audited and long-term follow-up is arranged for patients with complicated PICU course. For patients with acute medical conditions, after their condition is stabilised, they are considered for each of the ABCDEF elements. We carefully consider how to proceed, taking necessary precautions and correcting deviations, to ensure patient safety at all times. Patient-related factors, such as functional status, development, and nutrition, are considered individually. As a result, interventions in our PICU have progressed towards improving physical, psychological, and social sequelae.
 
Through implementing ICU Liberation practices, we have realised several key improvements. We have been able to actively mobilise patients who are still receiving mechanical ventilation, continuous renal replacement therapy, or intracranial pressure monitoring. We have actively engaged families, even during the coronavirus disease 2019 pandemic, by using communication tools such as digital photographs and videoconferencing software. We have facilitated family care even in complex medical conditions by training caregivers. And we have also extended family support to palliative care in the PICU, including home visits. In each case, the ICU Liberation bundle was carefully considered and tailored to according to individual assessment.
 
Barriers to ICU Liberation have been overcome by leadership and teamwork. Challenges present were owing to system factors and staff factors. In our future development we would address these challenges by developing clinical practice protocols, coordinating the roles of team members, and supporting staff knowledge and procedural competence. We propose focusing in future on further improvements to treating pain, facilitating spontaneous breathing, minimising sedation, preventing delirium, mobilising early, and engaging family members, in order to better support patient recovery. Further studies are warranted to evaluate implementation strategies for ICU Liberation and perceptions of ICU Liberation in our PICU.
 
Author contributions
All authors contributed to the concept or design of the study, acquisition, analysis, and interpretation of the data, drafting of the manuscript, and critical revision of the manuscript for important intellectual content. All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.
 
Conflicts of interest
As an editor of the journal, KL Hon was not involved in the peer review process. Other authors have disclosed no conflicts of interest.
 
Funding/support
This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
 
References
1. Ely EW. The ABCDEF Bundle: science and philosophy of how ICU liberation serves patients and families. Crit Care Med 2017;45:321-30. Crossref
2. Marra A, Ely EW, Pandharipande PP, Patel MB. The ABCDEF bundle in critical care. Crit Care Clin 2017;33:225-43. Crossref
3. Pun BT, Balas MC, Barnes-Daly MA, et al. Caring for critically ill patients with the ABCDEF bundle. Crit Care Med 2019;47:3-14. Crossref
4. Walz A, Canter MO, Betters K. The ICU liberation bundle and strategies for implementation in pediatrics. Curr Pediatr Rep 2020;8:69-78. Crossref
5. Smith HA, Besunder JB, Betters KA, et al. 2022 Society of critical care medicine clinical practice guidelines on prevention and management of pain, agitation, neuromuscular blockade, and delirium in critically ill pediatric patients with consideration of the ICU environment and early mobility. Pediatr Crit Care Med 2022;23:e74-110. Crossref
6. Namachivayam P, Shann F, Shekerdemian L, et al. Three decades of pediatric intensive care: who was admitted, what happened in intensive care, and what happened afterward. Pediatr Crit Care Med 2010;11:549-55. Crossref
7. Manning JC, Pinto NP, Rennick JE, Colville G, Curley MA. Conceptualizing post intensive care syndrome in children—The PICS-p Framework. Pediatr Crit Care Med 2018;19:298-300. Crossref
8. Herrup EA, Wieczorek B, Kudchadkar SR. Characteristics of postintensive care syndrome in survivors of pediatric critical illness: a systematic review. World J Crit Care Med 2017;6:124-34. Crossref
9. Ebrahim S, Singh S, Hutchison JS, et al. Adaptive behavior, functional outcomes, and quality of life outcomes of children requiring urgent ICU admission. Pediatr Crit Care Med 2013;14:10-8. Crossref
10. Bronner MB, Knoester H, Sol JJ, Bos AP, Heymans HS, Grootenhuis MA. An explorative study on quality of life and psychological and cognitive function in pediatric survivors of septic shock. Pediatr Crit Care Med 2009;10:636-42. Crossref
11. Jones S, Rantell K, Stevens K, et al. Outcome at 6 months after admission for pediatric intensive care: a report of a national study of pediatric intensive care units in the United Kingdom. Pediatrics 2006;118:2101-8. Crossref
12. Ong C, Lee JH, Leow MK, Puthucheary ZA. Functional outcomes and physical impairments in pediatric critical care survivors: a scoping review. Pediatr Crit Care Med 2016;17:e247-59. Crossref
13. Nelson LP, Gold JI. Posttraumatic stress disorder in children and their parents following admission to the pediatric intensive care unit: a review. Pediatr Crit Care Med 2012;13:338-47. Crossref
14. Kukreti V, Shamim M, Khilnani P. Intensive care unit acquired weakness in children: critical illness polyneuropathy and myopathy. Indian J Crit Care Med 2014;18:95-101. Crossref
15. Shehabi Y, Bellomo R, Reade MC, et al. Early intensive care sedation predicts long-term mortality in ventilated critically ill patients. Am J Respir Crit Care Med 2012;186:724-31. Crossref
16. Bone MF, Feinglass JM, Goodman DM. Risk factors for acquiring functional and cognitive disabilities during admission to a PICU. Pediatr Crit Care Med 2014;15:640-8. Crossref
17. Smith HA, Gangopadhyay M, Goben CM, et al. Delirium and benzodiazepines associated with prolonged ICU stay in critically ill infants and young children. Crit Care Med 2017;45:1427-35. Crossref
18. Smith HA, Fuchs DC, Pandharipande PP, Barr FE, Ely EW. Delirium: an emerging frontier in the management of critically ill children. Crit Care Clin 2009;25:593-614. Crossref