Welcome to the World Shared Practice Forum.
I’m Dr. Adrienne Randolph, Senior Associate in Critical Care Medicine at Boston Children’s
Hospital, and Professor of Anesthesia and Pediatrics at Harvard Medical School.
We’re very pleased to have with us today Dr. Karen Choong.
Dr. Choong is a professor in the Department of Pediatrics and Critical Care at McMaster
University, and in the Department of Health Research Methods, Evidence, and Impact.
Today, following up on your video, “Early Rehabilitation in the PICU”, we now have
a brief video describing in detail how you mobilize a child in the PICU.
Dr. Choong.
In this presentation, I’m going to speak about how to implement early mobilization
in critically ill children.
I’m going to address why it is important to mobilize critically ill children, what
the goals of early mobilization are, what constitutes mobilization in this population,
when we should mobilize, and finally, some tips on how to mobilize critically ill children.
Why mobilize critically ill children?
We know that immobility is currently the standard of care in our pediatric ICUs.
In the study that we conducted, we found that 13% 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 while they’re in the pediatric ICU.
The time to mobilization depends on whether these patients are medical or they’re surgical.
It takes up to five days to mobilize a medical patient, and up to 14 days to mobilize a mechanically
ventilated child.
We are also very slow to consult rehabilitation services, meaning physiotherapy and occupational
therapy.
There is now ample adult data showing that immobility is harmful and affects almost every
organ system.
Immobility can give rise not just to short-term morbidity, such as increased ventilated duration
and increased length of stay, but also long-term physical and non-physical sequelae, such as
ICU-acquired weakness, as well as cognitive impairment, 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 ill patients is because immobility is harmful
and mobility is medicine.
This is not a new concept.
You can see that this study from 1972 began mobilizing mechanically ventilated adults.
In this 1972 paper, Dr. Ross said, “Early ambulation 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 and chair rest are minimized.”
And in fact, they used this mobility device in this paper in 1975, which is similar to
the ICU walker that has been developed for adults today.
Fast forward 40 years and there is no longer anecdotal evidence.
We now have systematic review evidence that, compared to other interventions in the ICU
to date, the only intervention effective in improving long-term physical function is exercise-based
mobility physiotherapy.
We’d like to turn now to ask the audience a question.
When you respond, please leave your city and country location.
Do any of you use a rehabilitation bundle in your PICU?
And now we’re back with Dr. Choong.
There is adult systematic review data now showing that early mobilization improves mobility
function and strength at the time of hospital discharge.
It also increases days alive and out of the hospital to 180 days.
Its effect on longer-term outcomes, such as functioning, however, is unclear.
We also conducted a systematic review of early mobilization in critically ill children and
we found only four studies, and so there’s less data available in pediatrics.
We only found one study that measured functional outcomes in the post-PICU period.
What we can tell from this systematic review, however, is that early mobilization guidelines
and interdisciplinary team support increases the proportion of patients who receive PICU-based
rehabilitation and improves the frequency and time to mobilization.
And so the goals of early mobilization are to reduce harm, meaning PICU-acquired complications
of weakness, delirium, and immobility, and improve functional recovery in the period
post-PICU.
Early mobilization can only be effective if supported by a rehabilitation bundle that
also addresses sedation and delirium, and that is the ABCDEF bundle.
There are challenges to mobilizing critically ill children.
Adults require active participation.
The target for mobilization in adults is ambulation and endurance.
In the pediatric population, however, we have a 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 children is heterogeneous.
And children will be children.
If they don’t want to mobilize, they just won’t.
And so our strategies that we use to mobilize critically ill children should be different
than in adults.
What constitutes mobilization in critically ill children?
This should be individualized and focused on progressive range of motion and increasing
mobility and strength.
We target the highest level of functional mobility each day, and this should be determined
by rehabilitation experts, meaning the physiotherapists and occupational therapists, in collaboration
with clinician experts.
The goal should be to mobilize patients to their 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 of bed mobility.
This is particularly relevant in children where the population is heterogeneous in age,
cognitive and functional ability, and subsequently, cannot always comply with activities.
When should we consider mobilizing critically ill children?
And this study by Puthucheary et al., published in JAMA 2013, showed that muscle atrophy occurs
early and is further accentuated depending on the degree of organ dysfunction.
The skeletal muscle wasting parallels diplomatic atrophy with non-spontaneous breathing, mechanically
ventilated adults.
We also know from adult studies that early mobilization during mechanical ventilation
can be associated with increased muscle strength at discharge the earlier it is implemented.
Defining “early” is difficult because there is not much data on when the most appropriate
time is.
Some studies define “early” as a period of time, meaning 48 to 72 hours, from PICU
admission, and other studies define it by a physiologic course of the patient’s condition.
What we recommend is that “early” should mean “early assessments”.
What we recommend is the early assessment of patients for the readiness and safety of
mobilization, meaning within 24 hours of PICU admission.
We define readiness for mobilization by systems-based safety criteria that should be individualized
for each patient and prompts a discussion with the multi-professional team.
We have demonstrated that mobility-based rehabilitation is safe and feasible in critically ill patients.
With increasing experience, we now have fewer and fewer contraindications.
With more experience, we’re making mobilization safer for our critically ill children.
We now know it is possible to awaken and mobilize infants and toddlers, patients who are unconscious
and uncooperative, and we also know that it’s safe to mobilize patients on ECMO.
We have fewer and fewer contraindications.
And you can see from this slide that we are able to mobilize patients with stimulus sensitive
seizures, patients on continuous renal replacement therapy, patients with cerebral palsy, patients
with intracranial pressure monitoring, and patients with spinal cord injury.
We conducted a systematic review and demonstrated that the adverse event rate related to early
mobilization is actually very low.
This is similar to the findings from an adult systematic review, showing that there were
only 2.6% of potential adverse events following 22,000 mobilization events in 7,500 patients.
So, what do we know about how frequently we should mobilize patients?
We don’t yet know about the appropriate dosing and frequency of mobilization in critically
ill children, so we derive this information from different populations.
We know the recommendation is that healthy children 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 mobilized for 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 that have been published is that children have
been mobilized from between 10 to 30 minutes one to two times a day.
There is no data regarding the ideal duration of mobility or physical rehabilitation critically
ill adults and children, and so we have to turn to exercise physiology.
It’s not just about the duration, but it’s about the level of intensity as well.
So what we recommend, with respect to mobilization dosage and frequency, is that children should
be mobilized a minimum of 30 minutes at least once a day, initially, and then we reassess
this prescription and response daily, and we also recommend that there is graded intensity
from passive to active assisted to more active mobilization.
We do understand, however, that there are potential benefits even with passive mobilization.
The duration of frequency depends on the patient’s underlying 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 mobility and arterial function.
We recommend that the prescription for mobilization is assessed daily and regularly in consultation
with the physiotherapists or occupational therapists.
We recommend that mobilization is goal-directed and tailored to the patient’s tolerance
and strength, targeting the highest level of functional mobility every day.
I have some tips on implementation of mobilization in 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, such as safety concerns and the liberal use of
sedation, because we fear mobility in patients.
There is a unit culture and there’s a lack of knowledge and comfort with mobilization.
And so mobilization is a low priority in some PICUs today.
There are also patient-specific factors, with respect to their disease process.
But there’s also patient noncompliance.
As I mentioned, these are children, and children will be children.
If they don’t want to mobilize, it’s difficult to get them engaged.
And so we have to think about ways of engaging them so that we can get them to participate
in this activity.
There are also organizational factors that may be a barrier to mobilization, such as
the lack of staffing, resources, and equipment.
Sedation continues to be the key barrier to mobilizing 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 implemented as 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 deliver this is to use the ABCDEF bundle, which we
called PICU Liber8 in our institution.
Using this bundle helps us decrease the time to mobilization, decrease length of sedation,
and decrease the use of benzodiazepines using a collective, evidence-based approach.
We know that using these best practice guidelines improves unit culture and team communication,
and it empowers our physiotherapists and occupational therapists, as well as our nurses, to mobilize.
We also know that it increases the proportion and frequency of mobilization in our patients.
We published these guidelines in the Journal of 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 guidelines implementation, this is what we do in our
unit.
We use preprinted order sets with automatic physiotherapy 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’ve deleted 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 appropriate activity, 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 daily goals for activity and sedation.
Every day, we ask, in each patient, “Is it safe to move?”
“What is the activity order?”
And, “Can we make mobilization happen?”
We schedule the activity just like we schedule anything else, such as transports, interventional
procedures, or diagnostic imaging.
Using the daily goals checklists to communicate this facilitates intraprofessional closed-loop
communication and makes it a priority.
Using these guidelines prompts us to ask every day, “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 day for each patient.
Instituting early mobilization is about instituting a culture of practice.
Not only do we ask these questions every day for our patients, we perform a safety huddle,
where we think about which patient can we liberate that day?
So it becomes a unit priority, not just an individual patient priority.
We use adjuncts to mobilization, and in our study using a cycle ergometer, we found that
the cycle ergometer facilitates mobilization and increases the duration of mobility-based
activities.
But cycling is not for every child.
There is only a select population that we can use cycling in.
And the reason for that is cycling is good for in-bed mobilization, but as soon as we
can wake our patients up, we actually use out-of-bed mobilization.
We use adjuncts for mobilization, such as pet therapy in this picture, but also interactive
video gaming, appropriate seating, cycle ergometry for in-bed mobilization, but also out-of-bed—specific
bicycles designed for actually mobilizing children in hospital.
As I mentioned, children will be children, and sometimes they are not compliant with
the activity, just as they may not be compliant with any of the other therapies.
So we try to make mobilization engaging and fun, using different toys, neurodevelopmental
play, and even music therapy.
We use Child Life to help encourage these patients 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 gives them hope when their child is offered rehabilitation.
And so engaging the parents really helps to encourage and motivate the children in mobilizing
as well.
We need to make mobilization sustainable in our units, so we use knowledge reservoirs,
as well as champions, and we also use a feedback and 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 made this a risk-based guideline.
Because even though the patient is at high risk, it’s not that we cannot mobilize these
patients, we just have to think about a different way of mobilizing these patients safely.
So what you’re saying is that now every patient fits criteria for mobilization.
It’s just how much the risk is associated with mobilization.
That’s right.
We changed our language from a contraindication to mobilization to now considering the risk.
If a patient is high risk, we weigh the risks to 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 lower risk, than a physiotherapist is empowered
to assess that patient and begin mobilization.
And if the patient is low risk, then even the nurse can initiate mobilization, or even
the family member.
Thank you so much.
That was very informative.
Thank you for sharing your PICU Liberate protocol with us.
You’re very welcome.
Thank you, Dr. Randolph.