Mobilization practices in critically ill children: a European point prevalence study (EU PARK-PICU)

Erwin Ista, Barnaby R Scholefield, Joseph C Manning, Irene Harth, Orsola Gawronski, Alicja Bartkowska-Śniatkowska, Anne-Sylvie Ramelet, Sapna R Kudchadkar, EU PARK-PICU Collaborators, Paul C Ritson, Filippia Nikolaou, Marjorie de Neef, Martin Kneyber, Kate Penny-Thomas, Christina Linton, Reinis Balmaks, Matthias Richter, Fabrizio Chiusolo, Corrado Cecchetti, Marco Roberti, Michela Di Furia, Chantal Grandjean, Bettina Nygaard, Yolanda Lopez, Tolga Koroglu, Tolga Besci, Roberta Da Rin Della Mora, Rachel S Agbeko, Emma Borrows, Nathalie Bochaton, Janet Mattsson, Anne Ksellmann, Barbara Hero, Jowita Rosada-Kurasinska, Magdalena Świder, Amabile Bonaldi, Cristina Giugni, Siva Oruganti, Simon Gates, Hazel Smith, Annelies van Zwol, Jenna Hills, Johanna Conroy, Mark Bebbington, Felix Neunhoeffer, Els Duval, Erwin Ista, Barnaby R Scholefield, Joseph C Manning, Irene Harth, Orsola Gawronski, Alicja Bartkowska-Śniatkowska, Anne-Sylvie Ramelet, Sapna R Kudchadkar, EU PARK-PICU Collaborators, Paul C Ritson, Filippia Nikolaou, Marjorie de Neef, Martin Kneyber, Kate Penny-Thomas, Christina Linton, Reinis Balmaks, Matthias Richter, Fabrizio Chiusolo, Corrado Cecchetti, Marco Roberti, Michela Di Furia, Chantal Grandjean, Bettina Nygaard, Yolanda Lopez, Tolga Koroglu, Tolga Besci, Roberta Da Rin Della Mora, Rachel S Agbeko, Emma Borrows, Nathalie Bochaton, Janet Mattsson, Anne Ksellmann, Barbara Hero, Jowita Rosada-Kurasinska, Magdalena Świder, Amabile Bonaldi, Cristina Giugni, Siva Oruganti, Simon Gates, Hazel Smith, Annelies van Zwol, Jenna Hills, Johanna Conroy, Mark Bebbington, Felix Neunhoeffer, Els Duval

Abstract

Background: Early mobilization of adults receiving intensive care improves health outcomes, yet little is known about mobilization practices in paediatric intensive care units (PICUs). We aimed to determine the prevalence of and factors associated with physical rehabilitation in PICUs across Europe.

Methods: A 2-day, cross-sectional, multicentre point prevalence study was conducted in May and November 2018. The primary outcome was the prevalence of physical therapy (PT)- or occupational therapy (OT)-provided mobility. Clinical data and data on patient mobility, potential mobility safety events, and mobilization barriers were prospectively collected in patients admitted for ≥72 h.

Results: Data of 456 children admitted to one of 38 participating PICUs from 15 European countries were collected (456 patient days); 70% were under 3 years of age. The point prevalence of PT- and/or OT-provided mobility activities was 39% (179/456) (95% CI 34.7-43.9%) during the patient days, with significant differences between European regions. Nurses were involved in 72% (924/1283) of the mobility events; in the remaining 28%, PT/OT, physicians, family members, or other professionals were involved. Of the factors studied, family presence was most strongly positively associated with out-of-bed mobilization (aOR 7.83, 95% CI 3.09-19.79). Invasive mechanical ventilation with an endotracheal tube was negatively associated with out-of-bed mobility (aOR 0.28, 95% CI 0.12-0.68). Patients were completely immobile on 25% (115/456) of patient days. Barriers to mobilization were reported on 38% of patient days. The most common reported patient-related barriers were cardiovascular instability (n = 47, 10%), oversedation (n = 39, 9%), and medical contraindication (n = 37, 8%). Potential safety events occurred in 6% of all documented mobilization events.

Conclusion: Therapists are infrequently consulted for mobilization of critically ill children in European PICUs. This study highlights the need for a systematic and interdisciplinary mobilization approach for critically ill children.

Keywords: Critical care; Developmental paediatrics; Intensive care units; Occupational therapy; Paediatrics; Physical therapy; Rehabilitation.

Conflict of interest statement

All authors declare that they have no conflict of interest. All authors have completed and submitted the International Committee of Medical Journal Editors (ICMJE) form for disclosure of potential conflicts of interest.

Figures

Fig. 1
Fig. 1
Number of activities by clinician type. RN, registered nurse; PT, physical therapist; OT, occupational therapist; NP, nurse practitioner
Fig. 2
Fig. 2
Highest level of mobility
Fig. 3
Fig. 3
Adjusted odds ratio for out-of-bed mobility on study day. The multivariable model included random effect for site, adjusted for admission reason, gender, and ethnicity in addition to all characteristics listed. Vasoactive infusion excluded milrinone. HFNC, high-flow nasal cannula; CPAP, continuous positive airway pressure; MV, mechanical ventilation; ETT, endotracheal tube; PCPC, paediatric cerebral performance category; CVC, central venous catheter; PT, physical therapist; OT, occupational therapist; EM, early mobilization

References

    1. Kudchadkar SR, Yaster M, Punjabi NM. Sedation, sleep promotion, and delirium screening practices in the care of mechanically ventilated children: a wake-up call for the pediatric critical care community. Crit Care Med. 2014;42(7):1592–1600. doi: 10.1097/CCM.0000000000000326.
    1. Field-Ridley A, Dharmar M, Steinhorn D, McDonald C, Marcin JP. ICU-acquired weakness is associated with differences in clinical outcomes in critically ill children. Pediatr Crit Care Med. 2016;17(1):53–57. doi: 10.1097/PCC.0000000000000538.
    1. Dantas CM, Silva PF, Siqueira FH, Pinto RM, Matias S, Maciel C, Oliveira MC, Albuquerque CG, Andrade FM, Ramos FF, et al. Influence of early mobilization on respiratory and peripheral muscle strength in critically ill patients Influencia da mobilizacao precoce na forca muscular periferica e respiratoria em pacientes criticos. Rev Bras Ter Intensiva. 2012;24(2):173–178. doi: 10.1590/S0103-507X2012000200013.
    1. Curley MA, Quigley SM, Lin M. Pressure ulcers in pediatric intensive care: incidence and associated factors. Pediatr Crit Care Med. 2003;4(3):284–290. doi: 10.1097/01.PCC.0000075559.55920.36.
    1. Manning MJ, Gauvreau K, Curley MA. Factors associated with occipital pressure ulcers in hospitalized infants and children. Am J Crit Care. 2015;24(4):342–348. doi: 10.4037/ajcc2015349.
    1. Schweickert WD, Pohlman MC, Pohlman AS, Nigos C, Pawlik AJ, Esbrook CL, Spears L, Miller M, Franczyk M, Deprizio D, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet. 2009;373(9678):1874–1882. doi: 10.1016/S0140-6736(09)60658-9.
    1. Knoester H, Bronner MB, Bos AP. Surviving pediatric intensive care: physical outcome after 3 months. Intensive Care Med. 2008;34(6):1076–1082. doi: 10.1007/s00134-008-1061-4.
    1. Rennick JE, Rashotte J. Psychological outcomes in children following pediatric intensive care unit hospitalization: a systematic review of the research. J Child Health Care. 2009;13(2):128–149. doi: 10.1177/1367493509102472.
    1. Choong K, Fraser D, Al-Harbi S, Borham A, Cameron J, Cameron S, Cheng J, Clark H, Doherty T, Fayed N, et al. Functional recovery in critically ill children, the “WeeCover” multicenter study. Pediatr Crit Care Med. 2018;19(2):145–154. doi: 10.1097/PCC.0000000000001421.
    1. Schweickert WD, Kress JP. Implementing early mobilization interventions in mechanically ventilated patients in the ICU. Chest. 2011;140(6):1612–1617. doi: 10.1378/chest.10-2829.
    1. Wieczorek B, Ascenzi J, Kim Y, Lenker H, Potter C, Shata NJ, Mitchell L, Haut C, Berkowitz I, Pidcock F, 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. doi: 10.1097/PCC.0000000000000983.
    1. Kudchadkar SR, Nelliot A, Awojoodu R, Vaidya D, Traube C, Walker T, Needham DM, Prevalence of Acute Rehabilitation for Kids in the PI, the Pediatric Acute Lung I, Sepsis Investigators N et al: Physical Rehabilitation in Critically Ill Children: A Multicenter Point Prevalence Study in the United States. Crit Care Med. 2020;48(5):634–44.
    1. Parry SM, El-Ansary D, Cartwright MS, Sarwal A, Berney S, Koopman R, Annoni R, Puthucheary Z, Gordon IR, Morris PE, et al. Ultrasonography in the intensive care setting can be used to detect changes in the quality and quantity of muscle and is related to muscle strength and function. J Crit Care. 2015;30(5):1151 e1159–1151 e1114. doi: 10.1016/j.jcrc.2015.05.024.
    1. 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. doi: 10.1016/j.jpeds.2018.07.037.
    1. Patel BK, Pohlman AS, Hall JB, Kress JP. Impact of early mobilization on glycemic control and ICU-acquired weakness in critically ill patients who are mechanically ventilated. Chest. 2014;146(3):583–589. doi: 10.1378/chest.13-2046.
    1. PARK-PICU Data Collection Forms. . Accessed 28 Jan 2020.
    1. Fiser DH, Tilford JM, Roberson PK. Relationship of illness severity and length of stay to functional outcomes in the pediatric intensive care unit: a multi-institutional study. Crit Care Med. 2000;28(4):1173–1179. doi: 10.1097/00003246-200004000-00043.
    1. Jolley SE, Moss M, Needham DM, Caldwell E, Morris PE, Miller RR, Ringwood N, Anders M, Koo KK, Gundel SE, et al. Point prevalence study of mobilization practices for acute respiratory failure patients in the United States. Crit Care Med. 2017;45(2):205–215. doi: 10.1097/CCM.0000000000002058.
    1. Sprung CL, Cohen SL, Sjokvist P, Baras M, Bulow HH, Hovilehto S, Ledoux D, Lippert A, Maia P, Phelan D, et al. End-of-life practices in European intensive care units: the Ethicus Study. JAMA. 2003;290(6):790–797. doi: 10.1001/jama.290.6.790.
    1. Nydahl P, Sricharoenchai T, Chandra S, Kundt FS, Huang M, Fischill M, Needham DM. Safety of patient mobilization and rehabilitation in the intensive care unit. Systematic review with meta-analysis. Ann Am Thorac Soc. 2017;14(5):766–777. doi: 10.1513/AnnalsATS.201611-843SR.
    1. Fink EL, Beers SR, Houtrow AJ, Richichi R, Burns C, Doughty L, Ortiz-Aguayo R, Madurski CA, Valenta C, Chrisman M, et al. Early protocolized versus usual care rehabilitation for pediatric neurocritical care patients: a randomized controlled trial. Pediatr Crit Care Med. 2019;20(6):540–550. doi: 10.1097/PCC.0000000000001881.
    1. Wieczorek B, Burke C, Al-Harbi A, Kudchadkar SR. Early mobilization in the pediatric intensive care unit: a systematic review. J Pediatr Intensive Care. 2015;2015:129–170.
    1. Choong K, Foster G, Fraser DD, Hutchison JS, Joffe AR, Jouvet PA, Menon K, Pullenayegum E, Ward RE, Canadian Critical Care Trials G Acute rehabilitation practices in critically ill children: a multicenter study. Pediatr Crit Care Med. 2014;15(6):e270–e279. doi: 10.1097/PCC.0000000000000160.
    1. Ross K, Heiny E, Conner S, Spener P, Pineda R. Occupational therapy, physical therapy and speech-language pathology in the neonatal intensive care unit: patterns of therapy usage in a level IV NICU. Res Dev Disabil. 2017;64:108–117. doi: 10.1016/j.ridd.2017.03.009.
    1. Case-Smith J, Rogers S. Physical and occupational therapy. Child Adolesc Psychiatr Clin N Am. 1999;8(2):323–345. doi: 10.1016/S1056-4993(18)30183-4.
    1. Berney SC, Harrold M, Webb SA, Seppelt I, Patman S, Thomas PJ, Denehy L. Intensive care unit mobility practices in Australia and New Zealand: a point prevalence study. Crit Care Resusc. 2013;15(4):260–265.
    1. Nydahl P, Ruhl AP, Bartoszek G, Dubb R, Filipovic S, Flohr HJ, Kaltwasser A, Mende H, Rothaug O, Schuchhardt D, et al. Early mobilization of mechanically ventilated patients: a 1-day point-prevalence study in Germany. Crit Care Med. 2014;42(5):1178–1186. doi: 10.1097/CCM.0000000000000149.
    1. Sibilla A, Nydahl P, Greco N, Mungo G, Ott N, Unger I, Rezek S, Gemperle S, Needham DM, Kudchadkar SR. Mobilization of mechanically ventilated patients in Switzerland. J Intensive Care Med. 2020;35(1):55–62. doi: 10.1177/0885066617728486.
    1. Zheng K, Sarti A, Boles S, Cameron S, Carlisi R, Clark H, Khawaji A, Awladthani S, Al-Harbi S, Choong K. Impressions of early mobilization of critically ill children-clinician, patient, and family perspectives. Pediatr Crit Care Med. 2018;19(7):e350–e357. doi: 10.1097/PCC.0000000000001547.
    1. Hopkins RO, Choong K, Zebuhr CA, Kudchadkar SR. Transforming PICU culture to facilitate early rehabilitation. J Pediatr Intensive Care. 2015;4(4):204–211. doi: 10.1055/s-0035-1563547.
    1. Pun BT, Balas MC, Barnes-Daly MA, Thompson JL, Aldrich JM, Barr J, Byrum D, Carson SS, Devlin JW, Engel HJ, 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. doi: 10.1097/CCM.0000000000003482.
    1. Sottile PD, Nordon-Craft A, Malone D, Schenkman M, Moss M. Patient and family perceptions of physical therapy in the medical intensive care unit. J Crit Care. 2015;30(5):891–895. doi: 10.1016/j.jcrc.2015.04.119.
    1. Parisien RB, Gillanders K, Hennessy EK, Herterich L, Saunders K, Lati J, Dos Santos S, Hassall A, O'Brien KK. Experiences of four parents with physical therapy and early mobility of their children in a pediatric critical care unit: a case series. J Pediatr Rehabil Med. 2016;9(2):159–168. doi: 10.3233/PRM-160374.
    1. Bastani F, Abadi TA, Haghani H. Effect of family-centered care on improving parental satisfaction and reducing readmission among premature infants: a randomized controlled trial. J Clin Diagn Res. 2015;9(1):SC04–SC08.
    1. Dubb R, Nydahl P, Hermes C, Schwabbauer N, Toonstra A, Parker AM, Kaltwasser A, Needham DM. Barriers and strategies for early mobilization of patients in intensive care units. Ann Am Thorac Soc. 2016;13(5):724–730. doi: 10.1513/AnnalsATS.201509-586CME.
    1. Chohan S, Ash S, Senior L. A team approach to the introduction of safe early mobilisation in an adult critical care unit. BMJ Open Qual. 2018;7(4):e000339. doi: 10.1136/bmjoq-2018-000339.

Source: PubMed

Sponsors et collaborateurs

Les conditions médicales

Interventions en matière de drogue

3
S'abonner