Beginning Restorative Activities Very Early: Implementation of an Early Mobility Initiative in a Pediatric Onco-Critical Care Unit

Saad Ghafoor, Kimberly Fan, Sarah Williams, Amanda Brown, Sarah Bowman, Kenneth L Pettit, Shilpa Gorantla, Rebecca Quillivan, Sarah Schwartzberg, Amanda Curry, Lucy Parkhurst, Marshay James, Jennifer Smith, Kristin Canavera, Andrew Elliott, Michael Frett, Deni Trone, Jacqueline Butrum-Sullivan, Cynthia Barger, Mary Lorino, Jennifer Mazur, Mandi Dodson, Morgan Melancon, Leigh Anne Hall, Jason Rains, Yvonne Avent, Jonathan Burlison, Fang Wang, Haitao Pan, Mary Anne Lenk, R Ray Morrison, Sapna R Kudchadkar, Saad Ghafoor, Kimberly Fan, Sarah Williams, Amanda Brown, Sarah Bowman, Kenneth L Pettit, Shilpa Gorantla, Rebecca Quillivan, Sarah Schwartzberg, Amanda Curry, Lucy Parkhurst, Marshay James, Jennifer Smith, Kristin Canavera, Andrew Elliott, Michael Frett, Deni Trone, Jacqueline Butrum-Sullivan, Cynthia Barger, Mary Lorino, Jennifer Mazur, Mandi Dodson, Morgan Melancon, Leigh Anne Hall, Jason Rains, Yvonne Avent, Jonathan Burlison, Fang Wang, Haitao Pan, Mary Anne Lenk, R Ray Morrison, Sapna R Kudchadkar

Abstract

Introduction: Children with underlying oncologic and hematologic diseases who require critical care services have unique risk factors for developing functional impairments from pediatric post-intensive care syndrome (PICS-p). Early mobilization and rehabilitation programs offer a promising approach for mitigating the effects of PICS-p in oncology patients but have not yet been studied in this high-risk population.

Methods: We describe the development and feasibility of implementing an early mobility quality improvement initiative in a dedicated pediatric onco-critical care unit. Our primary outcomes include the percentage of patients with consults for rehabilitation services within 72 h of admission, the percentage of patients who are mobilized within 72 h of admission, and the percentage of patients with a positive delirium screen after 48 h of admission.

Results: Between January 2019 and June 2020, we significantly increased the proportion of patients with consults ordered for rehabilitation services within 72 h of admission from 25 to 56% (p<0.001), increased the percentage of patients who were mobilized within 72 h of admission to the intensive care unit from 21 to 30% (p=0.02), and observed a decrease in patients with positive delirium screens from 43 to 37% (p=0.46). The early mobility initiative was not associated with an increase in unplanned extubations, unintentional removal of central venous catheters, or injury to patient or staff.

Conclusions: Our experience supports the safety and feasibility of early mobility initiatives in pediatric onco-critical care. Additional evaluation is needed to determine the effects of early mobilization on patient outcomes.

Keywords: delirium; early mobility; occupational therapy; pediatric oncology; physical therapy; post-intensive care syndrome; quality improvement.

Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2021 Ghafoor, Fan, Williams, Brown, Bowman, Pettit, Gorantla, Quillivan, Schwartzberg, Curry, Parkhurst, James, Smith, Canavera, Elliott, Frett, Trone, Butrum-Sullivan, Barger, Lorino, Mazur, Dodson, Melancon, Hall, Rains, Avent, Burlison, Wang, Pan, Lenk, Morrison and Kudchadkar.

Figures

Figure 1
Figure 1
Interventions implemented through Plan-Do-Study-Act cycles to address each aspect of the ABCDEF intensive care unit liberation bundle. BRAVE, Beginning Restorative Activities Very Early; CAPD, Cornell Assessment of Pediatric Delirium; ERTs, extubation readiness trials; OT, occupational therapy; PT, physical therapy; RT, respiratory therapists.
Figure 2
Figure 2
Key driver diagram targeting early mobility of intensive care unit (ICU) patients. LOR, level of reliability; NP, nurse practitioner.
Figure 3
Figure 3
Key driver diagram targeting delirium. CAPD, Cornell Assessment of Pediatric Delirium; ICU, intensive care unit; LOR, level of reliability; LOS, length of stay; RASS, Richmond Agitation Sedation Scale.
Figure 4
Figure 4
Control chart for the percentage of patients who had consults for physical therapy (PT) and/or occupational therapy (OT) placed within 72 h of admission to the intensive care unit (ICU) for all length of stay. BRAVE, Beginning Restorative Activities Very Early; PDSA, Plan-Do-Study-Act.
Figure 5
Figure 5
Control chart for the percentage of patients who were mobilized within 72 h of admission to the intensive care unit (ICU) for all length of stay. BRAVE, Beginning Restorative Activities Very Early; OT, occupational therapy; PT, physical therapy; PDSA, Plan-Do-Study-Act.
Figure 6
Figure 6
Control chart for delirium screens, as defined as a Cornell Assessment of Pediatric Delirium (CAPD) score ≥ 9. BRAVE, Beginning Restorative Activities Very Early; CXRs, chest x-rays; ICU, intensive care unit.

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