ACCEPT ICU STUDY: Compliance With ICU Liberation Bundle in LMICs

Introduction: With a high burden of critical illness, low-middle-income countries (LMICs) are most affected by the long-term consequences following Intensive Care Unit (ICU) admissions. To mitigate these consequences, the ICU liberation ABCDEF bundle was developed. The ACCEPT ICU study (Assessing Critical CarE Provider’s Thoughts on ICU Liberation in LMICs) sought to understand the compliance rates across bundle elements in LMICs.


Methods: A cross-sectional survey of a convenience sample of critical care clinicians in LMICs was conducted. Questions related to the level of compliance for each ABCDEF element were evaluated on a five-point Likert scale. High compliance” indicated a fully established process, while “non-compliance” reflected the absence of any process. Intermediate ratings represented varying levels of partial implementation. Descriptive statistics were used to analyze all element-specific compliance rates.


Results: Out of the 370 Critical Care providers who completed the survey, compliance varied significantly, with 40% stating that some process was in place to measure compliance with ICU liberation. Choice of analgesia and sedation (Element C) had a 72% compliance rate for “High compliance” which was the highest compliance rate followed by 65%, 63%, and 61% for pain assessment and management (Element A), family engagement (Element F) and spontaneous awakening and breathing trials (Element B) respectively. Early mobilization (Element E) achieved a modest compliance rate of 55% for “High compliance”. Delirium management (Element D) emerged as the weakest performer, with only a 49% compliance rate for “High compliance”. Approximately one-third (32%) of respondents reported sporadic implementation, while 11% admitted non-compliance and 8% were unsure about practices in their units.


Conclusions: Our findings highlight inconsistencies in compliance with the ABCDEF bundle in LMICs. While analgesia selection and pain management show relatively good adherence, early mobilization and delirium management significantly lag behind. Implementing targeted interventions, such as standardized protocols, staff training, and integrating the bundle into the critical care workflow with regular monitoring of compliance, is essential for improving ICU patient outcomes in LMICs.