852 SECTION VI Pediatric Critical Care Neurologic should be incorporated into each child’s daily activity and can often occur when PTs and OTs are unavailable This includes when a child needs to retur[.]
852 S E C T I O N V I Pediatric Critical Care: Neurologic should be incorporated into each child’s daily activity and can often occur when PTs and OTs are unavailable This includes when a child needs to return to bed As such, nurses and other non-PT/OT staff should feel comfortable with transfers and ambulation Use of certified nurse assistants (CNAs) and rehabilitation technicians can allow more mobilization opportunities with less use of higher-skill-level personnel Another strategy is to alternate rehabilitation services to maximize frequencies In the following sections, strategies for implementation of acute rehabilitation and early mobility programs are discussed Implementation of Acute Rehabilitation in the Pediatric Intensive Care Unit: Evidence and Strategies The foundation of acute rehabilitation in the PICU is interdisciplinary collaboration and buy-in While equipment and funding for additional staff are always beneficial, building a mobility program from the ground up is predicated on teamwork to create a culture of mobility This interdisciplinary champion team must be composed of representatives from all stakeholder teams involved in patient care in the PICU (Fig 69.6) and may also include dietitians, social workers, administrative staff, and family advocates Once this team of champions has signed on, the next step in the development of a streamlined mobility program is to determine the unit and institutional barriers and facilitators unique to that PICU, using a validated model for quality improvement such as the Translating Evidence Into Practice (TRIP) model.12,75 From the beginning, it must be emphasized with the entire PICU staff that the end point for every PICU patient is not necessarily ambulation; rather, the goal of a mobility program is to individualize activities based on a child’s development, age, premorbid skills, and clinical status In order to accomplish this, it is critical to get the rehabilitation team to the bedside early in the admission to outline the process of a systematic approach to acute rehabilitation of the critically ill child Nurses Child Life Physicians PICU Rehab Team Respiratory Care PT/OT Pharmacist • Fig 69.6 Composition of the pediatric intensive care unit (PICU) acute rehabilitation team.OT, occupational therapy; PT, physical therapy Evidence in Support of Early Mobilization in the Pediatric Intensive Care Unit Prior to 2015, studies on early mobility in the PICU were small, single-center reports on specific patient populations or interventions that overall supported the safety and feasibility of PICU rehabilitation.14 In the first large-scale quality improvement study examining the safety and feasibility of an early mobilization program in the PICU setting, the PICU Up! Early Mobilization program was developed and tested in a 40-bed mixed medicalsurgical-cardiac ICU.12 The foundation of the program was a tiered activity plan with predetermined criteria to “rest and reassess.”12 Central to the activity plan was incorporation of sleep hygiene, routine delirium screening, and sedation scoring for all patients In this pre-post implementation study, children ages day to 17 years were included if they were admitted to the PICU for longer than 72 hours The primary outcome of the study was treatment and PT or OT evaluation by PICU day After implementation of the PICU Up! program, there was a significant increase in occupational therapy consultations by day and, notably, the median number of mobilizations per child doubled, from to 6, with no adverse events In a secondary analysis of the preimplementation group, the PICU Up! team demonstrated that before implementation of a streamlined program, children with normal baseline function and lower acuity of illness were significantly less likely to receive consultation from a rehabilitation team therapist These findings suggested that there was an implicit bias from the medical team that children with no baseline deficits would be less likely to have functional decline despite previous data demonstrating that all PICU patients are at some risk of functional decline.76 Subsequent studies evaluating implementation of PICU mobility programs have demonstrated success in unit-based practice change using similar interdisciplinary and multicomponent approaches.10,77,78 Surveys of PICU providers confirm that most staff feel that early mobilization is beneficial However, substantial concerns include safety issues such as potential endotracheal tube and central venous catheter dislodgement.79,80 As such, practice recommendations and pathways are available for multidisciplinary teams seeking guidance on best practices for early mobility program implementation with a focus on safety.12,81 Clinicians also voiced concern about a lack of streamlined functional outcome assessment directly relevant to rehabilitation, an area of research undergoing investigation.80,82 While outcomes data are limited for the PICU population, clinical trials are ongoing.82 Single-center studies in specific populations, such as liver transplant patients, have shown reduced hospital length of stay and increased ambulation distance without assistance.15 Large-scale point prevalence studies of acute rehabilitation demonstrated a 4% potential safety event rate among 4700 activities in 1800 patients in the United States, with only two endotracheal tube dislodgments.6 Early Mobilization: The “E” in the ABCDEF ICU Liberation Bundle The ABCDEF bundle, an initiative from the Society of Critical Care Medicine,83 is an interdisciplinary, evidence-based and integrated approach to optimize the management of critically patients comprising the six interrelated components summarized in Box 69.1.9,84 In a quality improvement collaborative study of more than 15,000 adults in ICUs in the United States, implementation of CHAPTER 69 Acute Rehabilitation and Early Mobility in the Pediatric Intensive Care Unit • BOX 69.1 ICU Liberation ABCDEF Bundle • • • • • • Assess, prevent, and manage pain Both spontaneous awakening and breathing trials Choice of analgesia and sedation Delirium prevention, assessment, and management Early mobility and exercise Family engagement and empowerment 853 • BOX 69.2 Components of the TRIP Model • • • • • Forming an interdisciplinary team Summarizing the evidence Identifying facilitators and barriers to implementation Establishing performance measures Ensuring that all patients receive the intervention These steps are dynamic and often occur simultaneously Sustainability requires an iterative process and repetition after successful initial implementation Step 1: Form an Interdisciplinary Team PICU Up! is as easy as A B C D E F G ! Assess, prevent and manage pain Breathing trials Choice of analgesia and sedation Delirium: assess, prevent and manage Early mobility and exercise Family engagement and empowerment Good sleep • Fig 69.7 Elements of PICU Up! the ABCDEF bundle resulted in clinically meaningful and significant improvements in survival, mechanical ventilation use, coma, delirium, restraint-free care, ICU readmissions, and postICU discharge disposition.9 The impact on these outcomes was proportional to the level of compliance with the ABCDEF components, suggesting that incomplete bundle adherence was not as beneficial While the impact of ABCDEF bundle implementation in pediatrics is not yet known, the establishment of programs such as PICU Up!82 (Fig 69.7) and PICU Liber885 incorporated into this multicomponent approach—and modification to ABCDEFG, in which the G is “good sleep”—would logically be expected to have a positive impact on patient-centered outcomes Implementation of a Pediatric Intensive Care Unit Early Mobility Program: Strategies for Success Before implementation of any program, it is critical to choose a validated and systematic approach to quality improvement that can be understood and applied by the interdisciplinary team While many models and frameworks exist, the TRIP model75 features the interdisciplinary team as the consistent facilitator for success and has been proven to translate to practice change for both adult and pediatric mobility initiatives.12,86 The five main components of the TRIP model are summarized in Box 69.2 It is impossible to overemphasize the importance of interdisciplinary team champions (see Fig 69.6) in any PICU mobility initiative These champions must be committed to meeting consistently and on a regularly scheduled basis to maintain momentum It is also crucial to include senior leadership, such as the medical director and director of nursing, early in the process for organizational buy-in After formation of the team, a shared understanding of the current “state of the unit” is important, as it relates to barriers and facilitators related to mobility, as outlined in eBox 69.3 Additionally, each discipline champion should discuss discipline-related questions with colleagues and report back to the team to ensure that all stakeholder input has been considered The data obtained from these discussions are integral to program development and evaluation Step 2: Summarize the Evidence After the initial brainstorming session, the interdisciplinary champion team should review and summarize the current evidence base for ICU mobilization and liberation, including both pediatric and adult studies.7,9,13,87 Reviewing these data will provide the educational foundation for developing the unit-based program and serve as the infrastructure for development of unit-based learning later in the process Step 3: Identify Local Barriers to Implementation This step expands on the groundwork established in Steps and 2, allowing the team to dive deeper into contextual factors that will both challenge and facilitate the development of a PICU mobility program At this stage, interdisciplinary champions meet with ICU staff to (1) present the problem, (2) present the goal of the program, (3) identify barriers and solutions, and (4) highlight unit strengths that will lead to implementation success It is important to acknowledge that there may not be a solution to overcoming every barrier and that the envisioned mobility program may need to be adapted to fit the individual ICU’s resources Step 4: Establish Performance Measures Establishing performance measures meaningful to a specific PICU is critical to successful implementation of early mobility programs and facilitates accountability These may be process oriented (e.g., number of rehabilitation team referrals and/or sessions per ICU day) or outcomes based (e.g., length of PICU stay, duration of mechanical ventilation, disposition to rehab/floor/home) Step 5: Ensure That All Patients Receive the Intervention— The E’s This final multifaceted stage is contingent on sustained energy and enthusiasm of the interdisciplinary team Engage means that 853.e1 • eBOX 69.3 Key Questions for the Interdisciplinary Team Developing a Mobility Program Questions for the Interdisciplinary Champion Team • How does this unit currently define early mobility? • Who is referred for OT/PT/SLP services, when, and are there criteria for referral? • Are orders required for OT/PT/SLP consultations? • When are physiatrists asked to consult, and what questions are asked? • What is the default activity level in the order set? • Which children are allowed out of bed? • Are families engaged in mobility in our ICU? • What are the sedation and pain management practices, and how they affect mobility? • What equipment exists to facilitate in- and out-of-bed activities, and where is this equipment stored? • Are therapists turned away when they approach the bedside and, if so, why? • What would facilitate early mobility in this pediatric ICU? Questions for Discipline-Specific Meetings • What is our discipline’s (nursing/RT/NP/physician/child life/rehab team) current role in early mobility? What we think it should be? • What are our specific concerns about a unit-based mobility program? • Do we have the resources (staff, equipment, education) needed to facilitate mobility? • Do we have the support of our discipline’s leadership to promote mobility in the PICU? ICU, Intensive care unit; NP, nurse practitioner; OT, occupational therapist; PICU, pediatric intensive care unit; PT, physical therapist; RT, rehabilitation therapist; SLP, speech-language pathologist 854 S E C T I O N V I Pediatric Critical Care: Neurologic • BOX 69.4 Key Components of a Pediatric Intensive Care Unit Early Mobility Protocol • Modifying the standard admission default activity level from “bed rest” to “as tolerated.” • Developing guidelines for PT, OT, and SLP consults • Developing guidelines for a physiatrist consultation • Modifying unit huddles and rounds to incorporate the discussion of mobility • Developing contraindications and precautions to mobilization based on the literature and patient characteristics.46,50,51 • Developing unit-specific guidelines regarding safe mobilization of the child The guidelines should include (1) when children may be safely mobilized; (2) activities in which the child may participate; (3) preparation for the activity; (4) provider roles and responsibilities during the activity; and (5) criteria for pausing the activity, resting, and reassessing • Developing supporting protocols and policies that are always accessible to all staff OT, Occupational therapist; PT, physical therapist; SLP, speech-language pathologist everyone on the ICU staff is invested in the program’s importance and success Educate ensures that all staff members have the knowledge needed to facilitate the mobility program’s goals and considers each discipline’s specific needs (e.g., teaching nurses how to use the bedside lifts, educating physicians on the different roles of rehabilitation team members) Execute equates to creating the standardized process for implementation of the program, which should, at minimum, include all the elements shown in Box 69.4 Finally, Evaluate puts into action the performance measures identified in Step 4, with consistent reporting to staff of progress from baseline data for unit accountability to achievement of goals Summary Acute rehabilitation and early mobilization of the critically ill infant and child is feasible and can be done safely, with potential positive impacts on short- and long-term outcomes As data emerge to support mobility in the PICU, critical care practitioners can engage the expertise and support of the pediatric rehabilitation team early in a child’s admission to mitigate the undesirable effects of prolonged PICU care Collaborating with the rehabilitation team is not only integral to optimizing a child’s individualized care but is central to educating PICU staff about the spectrum of activities that may benefit PICU patients Key References Manning JC, Pinto NP, Rennick JE, Colville G, Curley MAQ Conceptualizing post intensive care syndrome in children: the PICS-p framework Pediatr Crit Care Med 2018;19(4):298-300 Kudchadkar SR, Nelliot A, Awojoodu R, et al, for the Prevalence of Acute Rehabilitation for Kids in the PICU (PARK-PICU) Investigators and the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network Physical rehabilitation in critically ill children: a multicenter point prevalence study in the United States Crit Care Med 2020;48(5):634–644 Pun BT, Balas MC, Barnes-Daly MA, et al Caring for critically ill patients with the ABCDEF bundle: results of the ICU Liberation Collaborative in over 15,000 adults Crit Care Med 2019;47(1):3-14 Wieczorek B, Ascenzi J, Kim Y, et al PICU Up!: Impact of a quality improvement intervention to promote early mobilization in critically ill children Pediatr Crit Care Med 2016;17(12):e559-e566 Cuello-Garcia CA, Mai SHC, Simpson R, Al-Harbi S, Choong K Early mobilization in critically ill children: a systematic review J Pediatr 2018;203:25-33.e6 Gillies D, Wells D, Bhandari AP Positioning for acute respiratory distress in hospitalised infants and children Cochrane Database Syst Rev 2012;(7):CD003645 Costello JM, Patak L, Pritchard J Communication vulnerable patients in the pediatric ICU: enhancing care 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2014;42(3):656-663 42 Curley MA, Harris SK, Fraser KA, Johnson RA, Arnold JH State Behavioral Scale: a sedation assessment instrument for infants and young children supported on mechanical ventilation Pediatr Crit Care Med 2006;7(2):107-114 43 Kerson AG, DeMaria R, Mauer E, et al Validity of the Richmond Agitation-Sedation Scale (RASS) in critically ill children J Intensive Care 2016;4:65 ... activities, and where is this equipment stored? • Are therapists turned away when they approach the bedside and, if so, why? • What would facilitate early mobility in this pediatric ICU? Questions... Interdisciplinary Team PICU Up! is as easy as A B C D E F G ! Assess, prevent and manage pain Breathing trials Choice of analgesia and sedation Delirium: assess, prevent and manage Early mobility... the establishment of programs such as PICU Up!82 (Fig 69.7) and PICU Liber885 incorporated into this multicomponent approach—and modification to ABCDEFG, in which the G is “good sleep”—would logically