{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,22]],"date-time":"2026-07-22T15:01:01Z","timestamp":1784732461588,"version":"3.55.0"},"reference-count":37,"publisher":"MDPI AG","issue":"4","license":[{"start":{"date-parts":[[2026,7,22]],"date-time":"2026-07-22T00:00:00Z","timestamp":1784678400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Pediatr. Rep.","Pediatric Reports"],"abstract":"<jats:p>Background\/Objectives: Children with cancer admitted to the pediatric intensive care unit (PICU) are at increased risk for post-intensive care syndrome (PICS-p) due to prolonged immobility, deep sedation, and severe illness. The ABCDEF bundle offers a framework for enhancing ICU care and patient recovery, but implementing all components in pediatric oncology patients is challenging. This study assesses the development and implementation of the BRAVE (Beginning Restorative Activities Very Early) initiative, specifically BRAVE2, to integrate the comprehensive ABCDEF bundle and a nurse-led mobility program, in collaboration with rehabilitation specialists, within a pediatric oncology intensive care unit. Methods: BRAVE2 was a quality improvement project conducted in a single pediatric ICU from 2022 to 2023. We analyzed ICU data to assess patient demographics, frequency of physical and occupational therapy (PT\/OT) consultations, time to initial mobilization, and delirium screening rates (CAPD score of 9 or higher) for patients with ICU stays over 48 h. BRAVE2 addressed all elements of the ABCDEF bundle, including regular pain assessments, evaluation of spontaneous breathing readiness, sedation adjustments, delirium screening, early mobilization, and family engagement. Outcomes were monitored using statistical process control methods. Results: Of 140 patients, 117 (84%) remained in the ICU for more than 48 h. The delirium screening rate was 15.5%, consistently below the target of 30%. PT\/OT consultations within 72 h occurred in 80.7% of patients, and early mobilization in 49.7% of patients, both below the 80% goal. However, 90.4% of patients with tracked mobility were able to ambulate during their ICU stay. No mobility-related safety incidents were reported. Conclusions: Rolling out a full ICU liberation plan in a pediatric oncology ICU is possible, and implementing a comprehensive one is feasible and sustainable despite challenges. Although therapist-led early mobilization did not meet targets, incorporating nurse-led mobility strategies and routine delirium screening has established a scalable model to enhance ICU care and support long-term recovery for these patients.<\/jats:p>","DOI":"10.3390\/pediatric18040099","type":"journal-article","created":{"date-parts":[[2026,7,22]],"date-time":"2026-07-22T13:25:46Z","timestamp":1784726746000},"page":"99","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Beginning Restorative Activities Very Early: A Quality Improvement Project to Advance ABCDEF Bundle Practice in a Pediatric Oncology Intensive Care Unit"],"prefix":"10.3390","volume":"18","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-3112-8739","authenticated-orcid":false,"given":"Elizabeth","family":"Christian","sequence":"first","affiliation":[{"name":"Division of General Surgery, Department of Pediatric Trauma, Le Bonheur Children\u2019s Hospital, Memphis, TN 38103, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sarah","family":"Williams","sequence":"additional","affiliation":[{"name":"Center of Advanced Practice, Department of Nursing, St. Jude Children\u2019s Research Hospital, Memphis, TN 38105, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sara Tyson","family":"Husband","sequence":"additional","affiliation":[{"name":"Department of Nursing, St. Jude Children\u2019s Research Hospital, 262 Danny Thomas Place, Memphis, TN 38105, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Amanda","family":"Brown","sequence":"additional","affiliation":[{"name":"Center of Advanced Practice, Department of Nursing, St. Jude Children\u2019s Research Hospital, Memphis, TN 38105, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mohammad","family":"Sabobeh","sequence":"additional","affiliation":[{"name":"Department of Pediatric Critical Care, University of Tennessee Health Science Center, Memphis, TN 38163, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sarah","family":"Schwartzberg","sequence":"additional","affiliation":[{"name":"Department of Rehabilitation Services, St. Jude Children\u2019s Research Hospital, 262 Danny Thomas Place, Memphis, TN 38105, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0006-4617-0541","authenticated-orcid":false,"given":"Eliza","family":"Hendrix","sequence":"additional","affiliation":[{"name":"Department of Rehabilitation Services, St. Jude Children\u2019s Research Hospital, 262 Danny Thomas Place, Memphis, TN 38105, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sherry","family":"Locket","sequence":"additional","affiliation":[{"name":"Department of Rehabilitation Services, St. Jude Children\u2019s Research Hospital, 262 Danny Thomas Place, Memphis, TN 38105, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0000-4019-7440","authenticated-orcid":false,"given":"Deni","family":"Trone","sequence":"additional","affiliation":[{"name":"Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children\u2019s Research Hospital, 262 Danny Thomas Place, Memphis, TN 38105, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jennifer","family":"Featherston","sequence":"additional","affiliation":[{"name":"Department of Information Services, St. Jude Children\u2019s Research Hospital, 262 Danny Thomas Place, Memphis, TN 38105, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shankari","family":"Kalyanasundaram","sequence":"additional","affiliation":[{"name":"Department of Information Services, St. Jude Children\u2019s Research Hospital, 262 Danny Thomas Place, Memphis, TN 38105, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shilpa","family":"Gorantla","sequence":"additional","affiliation":[{"name":"Office of Quality and Patient Safety, St. Jude Children\u2019s Research Hospital, 262 Danny Thomas Place, Memphis, TN 38105, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maham","family":"Alam","sequence":"additional","affiliation":[{"name":"Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children\u2019s Research Hospital, 262 Danny Thomas Place, Memphis, TN 38105, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0000-3389","authenticated-orcid":false,"given":"Zhongheng","family":"Cai","sequence":"additional","affiliation":[{"name":"Department of Biostatistics, St. Jude Children\u2019s Research Hospital, 262 Danny Thomas Place, Memphis, TN 38105, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4457-7349","authenticated-orcid":false,"given":"Haitao","family":"Pan","sequence":"additional","affiliation":[{"name":"Department of Biostatistics, St. Jude Children\u2019s Research Hospital, 262 Danny Thomas Place, Memphis, TN 38105, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Saad","family":"Ghafoor","sequence":"additional","affiliation":[{"name":"Department of Pediatric Critical Care, University of Tennessee Health Science Center, Memphis, TN 38163, USA"},{"name":"Division of Critical Care Medicine, Department of Pediatric Medicine, St. Jude Children\u2019s Research Hospital, 262 Danny Thomas Place, Memphis, TN 38105, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,7,22]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"153","DOI":"10.1016\/j.critrevonc.2019.07.014","article-title":"PICU mortality of children with cancer admitted to pediatric intensive care unit a systematic review and meta-analysis","volume":"142","author":"Asperen","year":"2019","journal-title":"Crit. 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