ICU survivors are at risk of Post-Intensive Care Syndrome (PICS ), which can affect different dimensions such as physical, cognitive, and mental health. The ABCDEF bundle is a set of evidence-based multidisciplinary interventions that have been used as a strategy to prevent PICS. However, its adherence remains suboptimal, demonstrating the need for the implementation of improvement processes. In this study, we assessed the impact of using Kamishibai cards on the quality improvement of process.

The research was conducted in an adult ICU of a public hospital, involving consecutively admitted patients between January and March 2024. Compliance with the last 24-hour bundle was assessed using a checklist when the Kamishibai board (K-board) and Kamishibai cards (K-cards) were incorporated into the quality improvement project. The interdisciplinary team used simple and easy-to-handle materials for construction. The K- board dimensions were 104 cm x 87 cm, with 8 columns and 9 rows. The first column represented the names of each bundle component, and the remaining columns represented the days of the week. The K-card dimensions were 9.5 cm x 7.0 cm, and were placed on the respective days of the week for visual guidance. Each component could have up to 10 K- cards/day, allowing monitoring of the completion of each process per bed. Compliance was evaluated using the ‘all or nothing’ approach. A red K-card indicating non-adherence if any process item was not executed, while a green K-card indicating full adherence if all processes and beds had completed everything. The K-board was placed inside the ICU.

Ninety-four patients were included, a mean age of 58 years, 43.9% female, and 67.3% of mixed race. Among the 8 elements of the bundle, only element D (Delirium) showed adherence >95%. Throughout the month, elements A, B, and F reached values above 85%, and overall adherence by the end of January closed at 60%. The following month, a progressive increase in adherence was observed in all elements, except for C (RASS target) and E (early mobilization), yet the overall adherence rate increased to 81%. The growth continued progressively, with overall adherence reaching 92% in March. Even considered the lowest-performing, early mobilization rose from 37% to 50%, reaching 65%.

This original study using the Kamishibai cards demonstrated an increase in the overall adherence to the ABCDEF bundle from 60% to 92%. The strength of this tool lies in visual communication for the workteam. We intend to correlate the improvement in adherence with clinical outcomes.