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

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.

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

“…Otherwise, the nurse and families are provided with written instructions for mobility activities. As a part of this initiative, nurses, other staff members, and caregivers were educated and empowered to actively participate in mobility activities, an essential aspect of early mobility in critically ill children (28,29).…”

“…Early mobility is a promising therapeutic option that addresses many of these issues. Although adult studies suggest clinical benefit from early mobility and rehabilitation (25)(26)(27), the use of rehabilitation resources is low in the pediatric population, with a point prevalence of 35-39% (28,29). Early mobility-based rehabilitation programs designed to increase mobilization within 72 h of ICU admission in pediatrics are reported to be both safe and feasible and to increase physical/ occupational therapy consults and early mobilization events (30)(31)(32)(33)(34).…”

Building a culture of early mobilization in the pediatric intensive care unit—a nuts and bolts approach

“…"-Florence Nightingale Many perceived barriers to EM in the PICU have been reported in different studies, at the level of patient, provider, institution and knowledge translation (34,51). Resource and time constraints and increased workload are commonly cited; safety concerns are common, with patients often perceived as being "too sick" and physiologically unstable to safely tolerate mobilization, especially early in their admission; sedation practices may limit the cooperative ability of patients; the patients themselves may lack motivation or the ability to cooperate; the presence of invasive lines, airways and devices create concern about dislodging during movement; certain medications may be associated with increased risk; and delirium may further limit patient participation (29,31,32,34,35,52,(64)(65)(66)(67). Owing to these perceptions of risk, the youngest and sickest patients tend to receive the fewest rehabilitation interventions, and likely remain at the greatest risk of PICS (67).…”

“…quality improvement initiative (n=200) reported no associated adverse events with the use of a stratified early rehabilitation program (38). Similarly, recent point-prevalence (PARK-PICU) studies of mobilization practices in Europe and the USA reported only minor adverse events, most commonly transient changes in vital signs (31,32). Studies in specialized populations, for example following placement of ventricular assist devices, liver transplantation, and patients on extracorporeal membrane oxygenation (ECMO) awaiting lung transplantation have also not described serious adverse events associated with mobilization activities (45)(46)(47)(48).…”

“…The European (EU) PARK-PICU study reported that 46% of children were mobilized out of bed by nurses, therapists, family members and others. Of concern was that 43% of patients never received a physical-or occupational therapy referral, despite a median length of PICU stay of 11 days, and a quarter of patients were not mobilized at all owing to actual or perceived contraindications and over-sedation (31). Similarly, in the United States (US) PARK-PICU sites, one fifth of patients were reported to be completely immobile (32).…”