Welcome to the World Shared Practice Forum.
I’m Dr.
Adrienne Randolph, Senior Associatein Critical Care Medicine at Boston Children’s Hospital, and Professor of Anesthesia andPediatrics at Harvard Medical School.
We’re very pleased to have with us todayDr.
Karen Choong.
Dr.
Choong is a professor in the Departmentof Pediatrics and Critical Care at McMaster University, and in the Department of HealthResearch Methods, Evidence, and Impact.
Today, following up on your video, “EarlyRehabilitation in the PICU”, we now have a brief video describing in detail how youmobilize a child in the PICU.
Dr.
Choong.
In this presentation, I’m going to speakabout how to implement early mobilization in critically ill children.
I’m going to address why it is importantto mobilize critically ill children, what the goals of early mobilization are, whatconstitutes mobilization in this population, when we should mobilize, and finally, sometips on how to mobilize critically ill children.
Why mobilize critically ill children? We know that immobility is currently the standardof care in our pediatric ICUs.
In the study that we conducted, we found that13% to 32% of children are mobilized while they’re in the pediatric ICU.
We know that we are slow to mobilize.
Only 9.
5% of children are mobilized whilethey’re in the pediatric ICU.
The time to mobilization depends on whetherthese patients are medical or they’re surgical.
It takes up to five days to mobilize a medicalpatient, and up to 14 days to mobilize a mechanically ventilated child.
We are also very slow to consult rehabilitationservices, meaning physiotherapy and occupational therapy.
There is now ample adult data showing thatimmobility is harmful and affects almost every organ system.
Immobility can give rise not just to short-termmorbidity, such as increased ventilated duration and increased length of stay, but also long-termphysical and non-physical sequelae, such as ICU-acquired weakness, as well as cognitiveimpairment, depression, and delirium.
These can affect a child’s functioning, as well as their quality of life, long after they leave the pediatric ICU.
So, the reason to mobilize critically illpatients is because immobility is harmful and mobility is medicine.
This is not a new concept.
You can see that this study from 1972 beganmobilizing mechanically ventilated adults.
In this 1972 paper, Dr.
Ross said, “Earlyambulation is clinically useful.
Patient acceptance is excellent.
And it is our impression that by early ambulation, weaning has been facilitated and hastened, and the problems of prolonged bed rest andchair rest are minimized.
” And in fact, they used this mobility devicein this paper in 1975, which is similar to the ICU walker that has been developed foradults today.
Fast forward 40 years and there is no longeranecdotal evidence.
We now have systematic review evidence that, compared to other interventions in the ICU to date, the only intervention effective inimproving long-term physical function is exercise-based mobility physiotherapy.
We’d like to turn now to ask the audiencea question.
When you respond, please leave your city andcountry location.
Do any of you use a rehabilitation bundlein your PICU? And now we’re back with Dr.
Choong.
There is adult systematic review data nowshowing that early mobilization improves mobility function and strength at the time of hospitaldischarge.
It also increases days alive and out of thehospital to 180 days.
Its effect on longer-term outcomes, such asfunctioning, however, is unclear.
We also conducted a systematic review of earlymobilization in critically ill children and we found only four studies, and so there’sless data available in pediatrics.
We only found one study that measured functionaloutcomes in the post-PICU period.
What we can tell from this systematic review, however, is that early mobilization guidelines and interdisciplinary team support increasesthe proportion of patients who receive PICU-based rehabilitation and improves the frequencyand time to mobilization.
And so the goals of early mobilization areto reduce harm, meaning PICU-acquired complications of weakness, delirium, and immobility, andimprove functional recovery in the period post-PICU.
Early mobilization can only be effective ifsupported by a rehabilitation bundle that also addresses sedation and delirium, andthat is the ABCDEF bundle.
There are challenges to mobilizing criticallyill children.
Adults require active participation.
The target for mobilization in adults is ambulationand endurance.
In the pediatric population, however, we havea broad developmental age range, 53% to 68% of children have some chronic co-morbidity, and up to 44% have functional disabilities.
And so target functional mobility in childrenis heterogeneous.
And children will be children.
If they don’t want to mobilize, they justwon’t.
And so our strategies that we use to mobilizecritically ill children should be different than in adults.
What constitutes mobilization in criticallyill children? This should be individualized and focusedon progressive range of motion and increasing mobility and strength.
We target the highest level of functionalmobility each day, and this should be determined by rehabilitation experts, meaning the physiotherapistsand occupational therapists, in collaboration with clinician experts.
The goal should be to mobilize patients totheir highest level of functional activity while ensuring safety.
We therefore describe greater levels of activity, according to the level of assistance required, and progressing them from in bed to out ofbed mobility.
This is particularly relevant in childrenwhere the population is heterogeneous in age, cognitive and functional ability, and subsequently, cannot always comply with activities.
When should we consider mobilizing criticallyill children? And this study by Puthucheary et al.
, publishedin JAMA 2013, showed that muscle atrophy occurs early and is further accentuated dependingon the degree of organ dysfunction.
The skeletal muscle wasting parallels diplomaticatrophy with non-spontaneous breathing, mechanically ventilated adults.
We also know from adult studies that earlymobilization during mechanical ventilation can be associated with increased muscle strengthat discharge the earlier it is implemented.
Defining “early” is difficult becausethere is not much data on when the most appropriate time is.
Some studies define “early” as a periodof time, meaning 48 to 72 hours, from PICU admission, and other studies define it bya physiologic course of the patient’s condition.
What we recommend is that “early” shouldmean “early assessments”.
What we recommend is the early assessmentof patients for the readiness and safety of mobilization, meaning within 24 hours of PICUadmission.
We define readiness for mobilization by systems-basedsafety criteria that should be individualized for each patient and prompts a discussionwith the multi-professional team.
We have demonstrated that mobility-based rehabilitationis safe and feasible in critically ill patients.
With increasing experience, we now have fewerand fewer contraindications.
With more experience, we’re making mobilizationsafer for our critically ill children.
We now know it is possible to awaken and mobilizeinfants and toddlers, patients who are unconscious and uncooperative, and we also know that it’ssafe to mobilize patients on ECMO.
We have fewer and fewer contraindications.
And you can see from this slide that we areable to mobilize patients with stimulus sensitive seizures, patients on continuous renal replacementtherapy, patients with cerebral palsy, patients with intracranial pressure monitoring, andpatients with spinal cord injury.
We conducted a systematic review and demonstratedthat the adverse event rate related to early mobilization is actually very low.
This is similar to the findings from an adultsystematic review, showing that there were only 2.
6% of potential adverse events following22, 000 mobilization events in 7, 500 patients.
So, what do we know about how frequently weshould mobilize patients? We don’t yet know about the appropriatedosing and frequency of mobilization in critically ill children, so we derive this informationfrom different populations.
We know the recommendation is that healthychildren should have 60 minutes of moderate to vigorous activity every day.
However, in the critically ill population, we are not sure what the appropriate duration is.
In adult trials, adults have been mobilizedfor 15 to 30 minutes one to two times a day, and in some studies, up to 60 minutes a day.
Our PICU experience from the studies thathave been published is that children have been mobilized from between 10 to 30 minutesone to two times a day.
There is no data regarding the ideal durationof mobility or physical rehabilitation critically ill adults and children, and so we have toturn to exercise physiology.
It’s not just about the duration, but it’sabout the level of intensity as well.
So what we recommend, with respect to mobilizationdosage and frequency, is that children should be mobilized a minimum of 30 minutes at leastonce a day, initially, and then we reassess this prescription and response daily, andwe also recommend that there is graded intensity from passive to active assisted to more activemobilization.
We do understand, however, that there arepotential benefits even with passive mobilization.
The duration of frequency depends on the patient’sunderlying condition, of course.
While I focused on mobility-based rehabilitation, there are benefits to passive exercise in patients who cannot actively participate, such as the prevention of skeletal muscle atrophy and the preservation of joint mobilityand arterial function.
We recommend that the prescription for mobilizationis assessed daily and regularly in consultation with the physiotherapists or occupationaltherapists.
We recommend that mobilization is goal-directedand tailored to the patient’s tolerance and strength, targeting the highest levelof functional mobility every day.
I have some tips on implementation of mobilizationin the PICU that we’ve learned from implementing this program in our unit.
There are many barriers to mobilization.
We know that there are ICU team factors, suchas safety concerns and the liberal use of sedation, because we fear mobility in patients.
There is a unit culture and there’s a lackof knowledge and comfort with mobilization.
And so mobilization is a low priority in somePICUs today.
There are also patient-specific factors, withrespect to their disease process.
But there’s also patient noncompliance.
As I mentioned, these are children, and childrenwill be children.
If they don’t want to mobilize, it’s difficultto get them engaged.
And so we have to think about ways of engagingthem so that we can get them to participate in this activity.
There are also organizational factors thatmay be a barrier to mobilization, such as the lack of staffing, resources, and equipment.
Sedation continues to be the key barrier tomobilizing critically ill patients.
In these two studies from the adult literature, 63.
5% of patients could not receive early mobilization because of sedation.
We recommend that mobilization be implementedas part of a bundled approach, and the reason for this is because it’s a complex intervention.
It’s not just about mobilization.
It’s about sedation reduction as well.
And the best way that we found to deliverthis is to use the ABCDEF bundle, which we called PICU Liber8 in our institution.
Using this bundle helps us decrease the timeto mobilization, decrease length of sedation, and decrease the use of benzodiazepines usinga collective, evidence-based approach.
We know that using these best practice guidelinesimproves unit culture and team communication, and it empowers our physiotherapists and occupationaltherapists, as well as our nurses, to mobilize.
We also know that it increases the proportionand frequency of mobilization in our patients.
We published these guidelines in the Journalof Pediatric Intensive Care in 2017, and there is another guideline that’s also been published, which is the PICU Up! guidelines from Johns Hopkins.
To facilitate early mobilization guidelinesimplementation, this is what we do in our unit.
We use preprinted order sets with automaticphysiotherapy consults.
We have a specific PICU activity order set, and we use daily goals checklists to prompt the delivery of mobilization.
In our admission order set to the PICU, we’vedeleted the entry for bed rest, because we believe that that’s not necessary.
The default activity is “activity as tolerated”, and that allows the physiotherapist to assess the patient and implement the appropriateactivity, as they are experts in mobilization.
We’ve made mobilization usual care by having‘activity as tolerated” as the default order for activity in our patients.
We use a daily goals checklist to set dailygoals for activity and sedation.
Every day, we ask, in each patient, “Isit safe to move?” “What is the activity order?” And, “Can we make mobilization happen?” We schedule the activity just like we scheduleanything else, such as transports, interventional procedures, or diagnostic imaging.
Using the daily goals checklists to communicatethis facilitates intraprofessional closed-loop communication and makes it a priority.
Using these guidelines prompts us to ask everyday, “Is it safe to move the patient?” “What is the activity goal for that day?” And, “When can we make it happen?” So we ask these three questions every dayfor each patient.
Instituting early mobilization is about institutinga culture of practice.
Not only do we ask these questions every dayfor our patients, we perform a safety huddle, where we think about which patient can weliberate that day? So it becomes a unit priority, not just anindividual patient priority.
We use adjuncts to mobilization, and in ourstudy using a cycle ergometer, we found that the cycle ergometer facilitates mobilizationand increases the duration of mobility-based activities.
But cycling is not for every child.
There is only a select population that wecan use cycling in.
And the reason for that is cycling is goodfor in-bed mobilization, but as soon as we can wake our patients up, we actually useout-of-bed mobilization.
We use adjuncts for mobilization, such aspet therapy in this picture, but also interactive video gaming, appropriate seating, cycle ergometryfor in-bed mobilization, but also out-of-bed—specific bicycles designed for actually mobilizingchildren in hospital.
As I mentioned, children will be children, and sometimes they are not compliant with the activity, just as they may not be compliantwith any of the other therapies.
So we try to make mobilization engaging andfun, using different toys, neurodevelopmental play, and even music therapy.
We use Child Life to help encourage thesepatients with play therapy to use their upper limb mobility.
Family engagement is key to mobilization.
There are no greater champions than the parents.
The parents look forward to physiotherapy.
They look forward to the child’s exercise, because they feel that it is something that the child can look forward to, and also givesthem hope when their child is offered rehabilitation.
And so engaging the parents really helps toencourage and motivate the children in mobilizing as well.
We need to make mobilization sustainable inour units, so we use knowledge reservoirs, as well as champions, and we also use a feedbackand audit mechanism.
We’ve reviewed our mobilization guidelines, and our second iteration is we have made it more simple.
We’ve taken out contraindications and madethis a risk-based guideline.
Because even though the patient is at highrisk, it’s not that we cannot mobilize these patients, we just have to think about a differentway of mobilizing these patients safely.
So what you’re saying is that now everypatient fits criteria for mobilization.
It’s just how much the risk is associatedwith mobilization.
That’s right.
We changed our language from a contraindicationto mobilization to now considering the risk.
If a patient is high risk, we weigh the risksto benefits of actually mobilizing that patient.
And if it’s felt that it may be more beneficial, then we think about what is the safest type of mobility therapy for that patient.
If that patient has a caution and is lowerrisk, than a physiotherapist is empowered to assess that patient and begin mobilization.
And if the patient is low risk, then eventhe nurse can initiate mobilization, or even the family member.
Thank you so much.
That was very informative.
Thank you for sharing your PICU Liberate protocolwith us.
You’re very welcome.
Thank you, Dr.
Randolph.
.
