Physical Rehabilitation in Critically Ill Children: A Multicenter Point Prevalence Study in the United States

Abstract

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.

Comfort-holding in critically ill children: a scoping review

“…Of 13,326 citations identified, 13 articles were included in our scoping review (Figure 1 ). Studies were published between 1989 and 2020 and included nine quantitative analyses, 28 , 45 , 56 – 62 three qualitative analyses, 63 – 65 and one mixed-methods analysis 66 (ESM, eTable 4). Of the 13 included studies, three had a primary outcome specifically related to comfort-holding 59 – 61 five assessed comfort-holding as part of end-of-life care, 56 , 58 , 63 – 65 three assessed it as part of generalized developmental care, 28 , 62 , 66 and two assessed comfort-holding as part of mobilization.…”

“…Of the 13 included studies, three had a primary outcome specifically related to comfort-holding 59 – 61 five assessed comfort-holding as part of end-of-life care, 56 , 58 , 63 – 65 three assessed it as part of generalized developmental care, 28 , 62 , 66 and two assessed comfort-holding as part of mobilization. 45 , 57 Holding was assessed according to four outcomes: 1) the frequency of holding and factors associated with frequency of holding (five studies), 28 , 45 , 58 , 61 , 62 2) outcomes for children who received comfort-holding (two studies) 59 , 61 3) the safety of comfort-holding (three studies), 45 , 60 , 62 and 4) the impact of comfort-holding on parental outcomes (seven studies) 56 , 57 , 60 , 63 – 66 ( Table ).

Figure Flow diagram of included studies

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“…In a point prevalence study of early mobilization in 82 PICUs in the United States, Kudchadkar et al found that 51% of children aged less than three years were held, and only 5% of those aged three years and older were held. 45 Similarly, Choong et al found that critically ill children were mobilized out of bed, including comfort-holding, on 36% of patient-days. 46 Given the potential benefit of comfort-holding for critically ill children as an intervention to prevent and manage pain and agitation, and the lack of adoption of this therapy, it is important to evaluate the state of knowledge on the use of comfort-holding in 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).…”