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Introduction: Mobilizing patients during an intensive care unit admission results in improved clinical and functional outcomes. The goal of this quality improvement project was to increase the percentage of patients in the pediatric intensive care unit (PICU) mobilized early from 62% to 80%. Early mobilization was within 18 hours of admission for nonmechanically ventilated (non-MV) patients and 48 hours for mechanically ventilated (MV) patients. Methods: We collected data from September 15, 2015, to December 15, 2016, identified key drivers and barriers, and developed interventions. Interventions included the development of an algorithm to identify patients appropriate for mobilization, management of barriers to mobilization, and education on the benefits of early mobilization. The percentage of PICU patients mobilized early; the percentage of patients with physical therapy, occupational therapy (OT), speech-language pathology (SLP), and activity orders; identified barriers; PICU and hospital length of stay (LOS) and discharge disposition, were compared between the pre- and postintervention groups and the non-MV and MV subgroups. The MV subgroup was too small for statistical testing. Results: All measures in the combined postintervention group improved and reached significance (<0.05), except for the percentage of SLP orders and discharged home. Percentage mobilized early increased 25%, activity orders 50%, physical therapist orders 14%, OT orders 11%, SLP orders 7%, and discharged home 6%. Hospital LOS decreased by 35%, and PICU LOS decreased by 34%. All measures in the postintervention, non-MV subgroup improved and reached significance (<0.05). Conclusions: This early mobilization program was associated with statistically significant improvements in the rate of early mobilization, activity and therapy orders, and hospital and PICU LOS.

Objectives: With decreasing mortality in PICUs, a growing number of survivors experience long-lasting physical impairments. Early physical rehabilitation and mobilization during critical illness are safe and feasible, but little is known about the prevalence in PICUs. We aimed to evaluate the prevalence of rehabilitation for critically ill children and associated barriers. Design: National 2-day point prevalence study. Setting: Eighty-two PICUs in 65 hospitals across the United States. Patients: All patients admitted to a participating PICU for greater than or equal to 72 hours on each point prevalence day. Interventions: None. Measurements and Main Results: The primary outcome was prevalence of physical therapy– or occupational therapy–provided mobility on the study days. PICUs also prospectively collected timing of initial rehabilitation team consultation, clinical and patient mobility data, potential mobility–associated safety events, and barriers to mobility. The point prevalence of physical therapy– or occupational therapy–provided mobility during 1,769 patient-days was 35% and associated with older age (adjusted odds ratio for 13–17 vs < 3 yr, 2.1; 95% CI, 1.5–3.1) and male gender (adjusted odds ratio for females, 0.76; 95% CI, 0.61–0.95). Patients with higher baseline function (Pediatric Cerebral Performance Category, ≤ 2 vs > 2) less often had rehabilitation consultation within the first 72 hours (27% vs 38%; p < 0.001). Patients were completely immobile on 19% of patient-days. A potential safety event occurred in only 4% of 4,700 mobility sessions, most commonly a transient change in vital signs. Out-of-bed mobility was negatively associated with the presence of an endotracheal tube (adjusted odds ratio, 0.13; 95% CI, 0.1–0.2) and urinary catheter (adjusted odds ratio, 0.28; 95% CI, 0.1–0.6). Positive associations included family presence in children less than 3 years old (adjusted odds ratio, 4.55; 95% CI, 3.1–6.6). Conclusions: Younger children, females, and patients with higher baseline function less commonly receive rehabilitation in U.S. PICUs, and early rehabilitation consultation is infrequent. These findings highlight the need for systematic design of rehabilitation interventions for all critically ill children at risk of functional impairments.

Objective: Evidence for successful and sustainable models that systematically identify and address family stress in the pediatric intensive care unit (PICU) remains scarce. Using an integrated improvement science and family engagement framework, we implemented a standardized family stress screening tool and response protocol to improve family experience and reduce family crises through the timely coordination of parent support interventions. Methods: We conducted this improvement initiative in the 12-bed PICU of a children’s hospital within a large, urban academic medical center. Our team, which included 2 family advisors, adapted a validated Distress Thermometer for use in pediatric intensive care. A co-designed family stress screening tool and response protocol were iteratively tested, refined, and implemented in 2015–2017. Process and outcome measures included screening and response reliability, parent satisfaction, and security calls for distressed families. Results: Over the 18 months, the percentage of families screened for stress increased from 0% to 100%. Among families who rated stress levels ≥5, 100% received the recommended response protocol, including family support referrals made and completed within 24 hours of an elevated stress rating. From 2015 to 2017, PICU parent satisfaction scores regarding emotional support increased from a mean score of 81.7–87.0 ( P < 0.01; 95% CI). The number of security calls for distressed families decreased by 50%. Conclusions: The successful implementation of a co-designed family stress screening tool and response protocol led to the timely coordination of parent support interventions, the improved family perception of emotional support, and reduced family crises in the PICU.

BackgroundAdult patients who are immobilized, mechanically ventilated (MV) and/or sedated for a prolonged period of time experience decreased quality of life, muscle atrophy, impaired cardiopulmonary endurance, and impaired mobility. Similar research in pediatric population is limited.ObjectivesDecrease time from Pediatric Intensive Care Unit (PICU) admission to first mobilizationAssess feasibility, efficacy, safety and financial benefits of a Pediatric Early Mobility (EM) ProgramMethodsBaseline data collected September 14, 2015 through December 31, 2015 indicated that 60% of patients were mobilized within the allotted time frame (18 hours for non-MV patients and 48 hours for MV patients) and the average time to mobilization was 20 hours. A survey determined barriers to EM were time, staff, equipment and training. An interdisciplinary team including physical, occupational, respiratory, child life and creative arts therapists, speech language pathology, nurses, physicians, and family advisors worked together to put several interventions into place. An algorithm was created to educate the team on criteria for mobilization, a scheduling system was trialed, and hands on training was initiated. Family advisors are assessing families' knowledge regarding EM benefits and their role in the process in order to incorporate family perspective and feedback.ResultsThe time from PICU admission to mobilization has decreased from 20 to 14 hours and 84% of patient are mobilized within the “allotted” time frame.ConclusionsTo date, EM in the PICU has proven to be safe and effective. Detailed data analysis, including analysis of clinical and financial information pending project completion.Figure 1Percent of PICU Patients Mobilized 18 Hours+ within Established Time Frame.Figure 2Time From PICU Admission to First Mobilization.

Well-known causes of zinc deficiency, also referred to as acrodermatitis enteropathica (AE), include defects in intestinal zinc transporters and inadequate intake, but a rare cause of acquired zinc deficiency discussed here is an iatrogenic nutritional deficiency caused by parenteral nutrition administered without trace elements. While zinc-depleted parenteral nutrition causing dermatosis of acquired zinc deficiency was first reported in the 1990s, it is now again relevant due to a national vitamin and trace element shortage. A high index of suspicion may be necessary to diagnose zinc deficiency, particularly because early clinical findings are nonspecific. We present this case of acquired zinc deficiency in a patient admitted to a pediatric intensive care unit for respiratory distress and atypical pneumonia, who subsequently developed a severe bullous eruption due to iatrogenic zinc deficiency but was treated effectively with enteral and parenteral zinc supplementation, allowing for rapid re-epithelialization of previously denuded skin. K E Y W O R D S acrodermatitis enteropathica, bullous, trace element shortage, zinc deficiency How to cite this article: Wiznia LE, Bhansali S, Brinster N, Al-Qaqaa YM, Orlow SJ, Oza V. Acquired acrodermatitis enteropathica due to zinc-depleted parenteral nutrition. Pediatr

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Invasive community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) infections disproportionately affect children, but there are few pediatric reports of pericarditis and mediastinitis caused by CA-MRSA in previously healthy children. Here we report a severe case of CA-MRSA pericarditis with extension to the mediastinum and carotid sheath in a previously healthy 8-month-old infant who was successfully treated with surgical interventions and with a combination of daptomycin and vancomycin. The relatively indolent clinical course in this patient was notable given the significant extent of infection. This case highlights the potential virulence of CA-MRSA in previously healthy children and the importance of early diagnosis, prompt drainage, and appropriate antibiotic coverage.