Connecting Clinical Practice Guidelines with Bundles, Implementation, and Quality Improvement Studies

In this issue of Pediatric Critical Care Medicine (PCCM) there are two new clinical practice guidelines (CPG) for medical management in the PICU. The first is from the Surviving Sepsis Campaign (SSC) and aims to update evidence-based recommendations for clinicians caring for children (including infants, school-aged children, and adolescents) with sepsis or septic shock (1). The second is from the Society of Critical Care Medicine (SCCM) and aims to develop and provide evidence-based recommendations for end-of-life (EOL) care and management of critically ill neonatal and pediatric patients and their families (2). This literature from our professional bodies can be added to six other specialty guidelines that have been published post-COVID-19 (3–8). What should we do with this new material, and how do we position the information in the hierarchy of clinical research? In answer, this next article in the Editor’s Notes series (with a focus on CPGs (9,10)) illustrates how PCCM views the hierarchy and progression in literature from CPGs to bundles, to implementation, to quality improvement studies. FROM GUIDELINES TO BUNDLES CPGs are a collection of systematically developed statements produced by a panel of medical experts to help us make the best decisions for managing patient conditions when there is variation in practice. In this context, the 2026 SSC pediatric sepsis or septic shock guidelines (1) update the 2020 guidelines (11), whereas the SCCM EOL pediatric guidelines are completely new material (2). Both reports have used systematic reviews (in accordance with the Journal’s criteria 12) to answer specific PICO (Patient, Intervention, Comparator, Outcome) questions. So, what do we want to happen to this type of information after publication in PCCM? One step that is often used is translation of the CPG material into bundles of care. In this usage, a clinical “bundle” often comprises a subset of three to five CPG statements or recommendations which, when carried out together, should result in better outcomes than when implemented individually. For example, a multicenter report from Bolivia in the February 2026 issue of PCCM examined “sepsis bundle” adherence and early vasopressor administration in a 2023 cohort of pediatric septic shock cases (13,14). The bundle was derived from the 2020 SSC pediatric septic shock guidelines (11), and incorporated those five components into early patient care: 1) oxygen therapy or endotracheal intubation in cases of respiratory failure, within the first 1 hour; 2) blood culture upon admission or before antibiotic treatment; 3) antibiotic treatment within the first 1 hour for septic shock and within the first 3 hours for sepsis cases; 4) fluid resuscitation by protocol within the first 1 hour or until signs of fluid overload; and 5) vasoactive agent infusions by protocol. The multicenter research group found that “timely sepsis bundle completion” and “early initiation of vasoactive agents” were independently associated with lower hazard of mortality. BUNDLE IMPLEMENTATION Next, in the new era of “implementation science,” researchers now seek ways to determine how best to integrate CPGs and bundled care into real-world practices in the PICU (15). For example, in the framework from CPGs to bundled care, to implementation, a well-developed trajectory in clinical research has followed the 2022 SCCM PANDEM CPGs (i.e., Prevention and Management of Pain, Agitation, Neuromuscular Blockade, and Delirium in Critically Ill Pediatric Patients With Consideration of the ICU Environment and Early Mobility) (4). Here, by way of background, consider the SCCM PICU liberation program (see https://sccm.org/clinical-resources/iculiberation-home). This program involves using the ABCDEF bundle (Assess, prevent manage pain; Both spontaneous awakening and breathing trials; Choice of analgesia and sedation; Delirium assessment, prevention, management; Early mobility and exercise; and Family engagement and empowerment) in practice, and it aligns with the recommendations in the 2022 SCCM PANDEM CPGs (4). To date, the research studies supporting the process of implementing these CPGs and the ABCDEF bundle has included: 1) identifying barriers to implementing the ICU liberation bundle (16); 2) assessing barriers to practitioner agreement on sedation goal setting and clinical scoring (17); 3) evaluating costs of implementing an early rehabilitation bundle (18); and 4) appraising bedside procedure and outcome-metrics that could be used to implement and judge an early rehabilitation bundle (19,20). Another illustration of making progress in implementing CPGs comes from the multicenter VentLib4Kids (i.e., ventilation liberation for kids) collaborative. In 2023, the collaborative published its CPGs (6), and over 2023/2024 it surveyed 26 PICUs (409 respondents) with the purpose of developing an implementation strategy (21). Based on the responses about feasibility, impact, and agreement, the next phase of work will likely focus on best options in “tiers” of implementation (21,22). That is, the area of work with the smallest gap between current practice and new practice to be implemented, and therefore considered top “tier A” to implement, was risk-stratified noninvasive respiratory support. An area with the largest practice gap and designated as bottom “tier C” for implementation was respiratory muscle strength testing. IMPLEMENTATION TO QUALITY IMPROVEMENT Implementation science and quality improvement complement each other, and both aim to translate evidence into practice (15,23). Implementation science offers strategies to overcome barriers to the “how” of evidence-based practice (see previous section). Quality improvement using CPGs focuses on context-specific iterations in achieving local best performance, and is exemplified in the plan-do-study-act (PDSA) cycle. However, the distinction between these forms of research may be an illusion since there is often overlap in the type and meaning of the work being carried out. In CPG-related quality improvement research, we again have data arising out of the 2022 SCCM PANDEM CPGs. These reports are often in the form of pre- versus postimplementation projects, such as the January 2026 article on having during rounds a structured, nurse-led discussion about the PICU liberation bundle (ABCDEF) (24). CONCLUSION The 2026 SSC pediatric sepsis or septic shock guidelines (1) and the 2026 SCCM EOL pediatric guidelines (2) are important additions to the 2022−2026 collection of CPGs in our specialty (1−8). The examples in this Editor’s Notes, however, show that the translation of CPGs to developing bundled care, implementing that care, and demonstrating improved quality of patient care can take years. To expedite the process to publication, we therefore now support and welcome all such work at PCCM. For us, the vital issue is advancing practice at a multicenter level and prioritizing the connections between experts who produce the CPGs and the practitioners who show us that CPG-related changes in PICU bedside care improves quality and outcomes.