Building a culture of early mobilization in the pediatric intensive care unit—a nuts and bolts approach

Abstract

The culture of sedation and immobilization in the pediatric intensive care unit (PICU) is associated with PICU-acquired weakness, delirium, and poor functional, neurocognitive and psychosocial outcomes. A structured approach to introducing physical activity, as early as possible after PICU admission, may prevent these complications and optimize the holistic outcomes of critically ill children. Changing culture and introducing new clinical practice in PICU is complex, but can be approached systematically, using a "nuts and bolts" approach targeting the basic, practical considerations and essential required elements or components. Extending the construction analogy, this article reviews the relevant literature to describe the essential elements required to build and sustain a successful and safe early mobility program in the PICU.Effective early mobilization requires individual patient assessment and goal setting, using a collaborative inter-disciplinary, patient-and family-centered approach, to ensure mobility goals and physical activities are appropriate for the patient's age, condition/s, premorbid function, strength, endurance and developmental level. Early mobility activities for the pediatric age spectrum include active or active-assisted range of motion exercises, neurodevelopmental play, use of mobility devices, in-bed exercises, transfers, sitting or standing tolerance, crawling, pre-gait activities, ambulation and activities of daily living, with a focus on play as function. Although there are few complete contraindications to early mobilization, appropriate precautions and preparation should be taken to mitigate potential safety concerns. Although there are many perceived barriers to early mobilization in the PICU, at the level of patient, provider, institution and knowledge translation; these are not objectively associated with increased risk during mobilization and can be overcome through an engaged process of practice change by all members of the interprofessional clinical team. Early mobility programs could be initiated in PICU as systematic quality improvement initiatives, with established processes to optimize structural, process and system elements and to provide continual feedback, measurement, benchmarking and collaboration; to ultimately impact on measurable patient outcomes. Early, graded, and individually prescribed mobilization should be considered as part of the standard PICU "package of care" for all critically ill and injured children, in order to improve their functional status and quality of life after PICU discharge.

Nonpulmonary Treatments for Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference

“…Most nonpharmacologic sleep promotion interventions are inexpensive and feasible approaches that can be implemented in both high- and low-resource PICUs (27). Although some reports of mobility interventions include devices such as cycle ergometers, custom built walkers, standing frames, and virtual reality consoles (95–97, 108, 109), many of these devices are associated with substantial financial cost and may not be globally available (110). Furthermore, there is no evidence that expensive devices are required for effective PICU-based rehabilitation, despite the lack of pediatric-specific mobility equipment being perceived as a barrier to implementation of EM (111).…”

Defining pediatric trauma center resource utilization: Multidisciplinary consensus-based criteria from the Pediatric Trauma Society

“…The initial literature review screened more than 200 articles, from which relevant articles were reviewed in detail. Twenty candidate criterion statements were developed based on published general/procedural criteria, 4,9–16 as well as specific criteria for emergent vascular access, 17–20 crystalloid volume/timing, 21 surgical intervention, 22,23 anesthesia/sedation, 24–28 intensive care, 29 transfusion, 30,31 blunt abdominal trauma/solid organ injury, 32–34 diagnostic/interventional radiology, 35–38 child abuse, 39,40 and rehabilitation 41–45 …”

“…Twenty candidate criterion statements were developed based on published general/procedural criteria, 4,[9][10][11][12][13][14][15][16] as well as specific criteria for emergent vascular access, [17][18][19][20] crystalloid volume/ timing, 21 surgical intervention, 22,23 anesthesia/sedation, [24][25][26][27][28] intensive care, 29 transfusion, 30,31 blunt abdominal trauma/solid organ injury, [32][33][34] diagnostic/interventional radiology, [35][36][37][38] child abuse, 39,40 and rehabilitation. [41][42][43][44][45] Fifteen panelists participated in the initial feedback session. Four statements were discarded after initial panelist feedback.…”

Modified ABCDEF-Bundles for Critically Ill Pediatric Patients - What Could They Look Like?

“…As with all other bundles, key is establishing a reliable protocol for daily review of the patients' goals, clear documentation of reached milestones for continuity of care and a multidisciplinary approach including rehabilitation specialists, nurses, doctors and parents, communicating different perspectives and defining common goals in daily rounds. Having a standardized protocol instead of individualized plans is associated with improved outcome and lessens the risk of implicit bias in planning the therapeutic approaches ( 76 , 78 ).…”