Introduction
In the Integrated Model of Care (IMOC), ICU personnel identify and address palliative care (PC) needs within the unit. Evidence-based tools like The Initiative for Pediatric Palliative Care (IPPC) guidelines are key to building international PC capacity. Identifying existing PC resources and competencies amongst potential IPPC adopters is vital to maximizing the implementation effectiveness of these guidelines.Do PICUs/NICUs around the world implement PPC? How? Do units’ infrastructure/human resources shape care provision and outcomes in relation to IPPC recommendations? Materials and methods	
This international, cross-sectional, prospective study included a convenience sample of PICUs/NICUs. Questionnaires were multiple choice and open-ended, focused on unit infrastructure, technology, and personnel ratios as well as on on policies, limited clinical/demographic data of a currently admitted patient sample, and practices related to the IPPC domains: 1) holistic care, 2) family support, 3) family unit involvement, 4) pain/symptom control, 5) continuity of care, 6) grief support. 
To evaluate IPPC adherence, we constructed a partial score for each domain and a total index by combining the scores for each domain. We compared average total and individual domain scores according to World Bank income. To assess statistical significance, we used multilevel generalized linear models (GLM) with a Gaussian distribution adjusted by child age/gender and used center as a clustering variable. High income countries (HIC) were used as a reference for statistical comparisons. We also evaluated structural/demographic predictors of total scores using univariate and multivariable multilevel GLM, using center as a clustering variable.
Our sample included 33 participating PICU/NICU from 18 countries in the Americas, Europe, Asia, and Africa (HIC:33.33%, UMIC:42.42%, LMIC/LIC:24.24%). All groups reported some compliance with all IPPC domains and no group reported perfect fulfillment of any domain. After adjusting for patient age/sex and clustering by unit, HIC had a higher total score than UMIC or LMIC/LIC (63.1% vs. 47.4% & 46.5%). This effect was only statistically significant for the comparison between HIC and UMIC (p-value=0.036). We found three statistically significant differences in IPPC scores between HIC and UMIC (Holistic care; Family involvement; HCP grief support) and two between HIC and LMIC (Family & HCP grief support). Centers with shorter shifts (<8 hrs.) scored higher.Conclusions
Our findings indicate that HCP already complete many PC tasks in PICU/NICU around the world, independent of income. Development, education, and barriers related to the implementation of evidence-based guidelines likely shaped IPPC scores. Similarly, UMIC may have scored lower than LMIC/LIC in Domains 1 and 3B because the economic transition in UMIC causes characteristics of wealthier economies (i.e. extreme specialty exclusivity) to collide with obstacles characteristic of LMIC/LIC (i.e. limited health education), thus limiting care quality. Identifying current PPC application can help maximize the implementation effectiveness of interventions like the IPPC recommendations to expand access to the human right to PPC.

INTEGRATED MODEL OF CARE IN PEDIATRIC AND NEONATAL INTENSIVE CARE UNITS: PAIN MANAGEMENT AROUND THE WORLD