Quality Improvement Methodology to Optimize Safe Early Mobility in a Pediatric Intensive Care Unit

Abstract

Introduction: Utilization of robust quality improvement methodology in conjunction with traditional interventions to enhance an Early Mobility program (EMP) in a tertiary pediatric intensive care unit (PICU). Methods: EMP was implemented in our PICU in May 2017. The percentage of appropriate physical and occupational therapist consults were determined. We also evaluated the activity levels received by the patient and the levels for which they qualified based on their medical condition. Failure Modes and Effects Analysis (FMEA) was performed to identify potential complications related to the mobilization of critically ill children. We created 4 simulation scenarios based on FMEA prioritized results. Results: After the implementation of EMP, appropriate physical and occupational therapist consults significantly increased (P < 0.0001). However, most patients still failed to receive the optimal level of activity recommended by protocol. This failure was partly due to concern for safety events during mobilization. FMEA identified vital sign changes [Risk Priority Number (RPN) 97.8], staff injury (RPN 64), and pain/anxiety (RPN 60.5) as potential safety events. We performed various in-situ simulation sessions based on these potential events. In post-simulation evaluations, 100% of participants agreed that the simulation experience would improve their performance in the actual clinical setting. Feedback from simulations led to the development of an EM patient safety checklist and clinical pathway. Conclusions: We describe a novel technique of using FMEA to develop scenarios that simulate potential adverse events to optimize safe EM in PICU. An EM checklist and pathway can guide in the implementation of safe EMP.

Barriers and perceived benefits of early mobilisation programmes in Dutch paediatric intensive care units

“…19,27 Also, as part of the implementation plan, an education programme for PICU staff with simulation sessions addressing barriers can improve their performance in the actual clinical setting. 13 The lack of equipment for early mobilisation was not considered an important barrier in our study. However, having access to sufficient equipment could facilitate the implementation of early mobilisation and increase mobility levels.…”

“…Also, clear guidelines can help PICU staff determine whether a patient can be mobilised and to what extent, with clear criteria with regard to patient‐related factors to address patient‐related barriers 19,27 . Also, as part of the implementation plan, an education programme for PICU staff with simulation sessions addressing barriers can improve their performance in the actual clinical setting 13 . The lack of equipment for early mobilisation was not considered an important barrier in our study.…”

“…9 Early mobilisation of critically ill children has been proven safe and feasible, with the potential to shorten both hospital and PICU length of stay. [10][11][12][13][14][15][16][17]…”

“…Early mobilisation encompasses interventions that aim to maintain or restore musculoskeletal strength in critically ill patients within 72 h of their admission, including those patients on invasive mechanical ventilation 9 . Early mobilisation of critically ill children has been proven safe and feasible, with the potential to shorten both hospital and PICU length of stay 10–17 …”

Movilización temprana en el paciente pediátrico crítico con soporte ventilatorio. experiencia de un centro de alta complejidad

“…Esta contradicción hace pensar que el paradigma de a poco va cambiando y ciertas barreras con el pasar del tiempo van dejando de serlo (14,15) . Posiblemente el hecho de contar con fisioterapeutas que tienen dedicación exclusiva en el área es uno de los motivos más relevantes que favorecen la MT al igual que la implementación de un protocolo con objetivos diarios de movilidad (30,(32)(33) . Nuestro estudio presenta limitaciones.…”