Development of an interdisciplinary program for early movement of critically ill children in the Paediatric Intensive Care Unit (PICU)
CCCF ePoster library. Ames K. Oct 26, 2015; 117309; P24 Disclosure(s): No disclosures
Ms. Kaitlin Ames
Ms. Kaitlin Ames
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Abstract
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P24


Topic: Quality Assurance/Quality Improvement Project


Development of an interdisciplinary program for early movement of critically ill children in the Paediatric Intensive Care Unit (PICU)



Kaitlin Ames, A. Hassal, G. Annich, S. Shah, C. Campbell, A. McCormick

Paediatric Intensive Care Unit, The Hospital for Sick Children, Toronto, Canada | Paediatric Intensive Care Unit, The Hospital for Sick Children, Toronto, Canada | Critical Care Medicine, The Hospital for Sick Children, Toronto, Canada | Critical Care Medicine, The Hospital for Sick Children, Toronto, Canada | Paediatric Intensive Care Unit, The Hospital for Sick Children, Toronto, Canada | Critical Care Medicine, The Hospital for Sick Children, Toronto, Canada

Introduction:

Literature documents that early movement/mobilization (EM) of patients in adult intensive care units is safe and reduces morbidity and length of stay (LOS)1. Despite experiencing similar morbidities2,3, there is a paucity of literature regarding EM of children in the pediatric intensive care unit (PICU). A consistent approach to EM that incorporates developmental considerations in the context of critical illness would inform the medical management and rehabilitation of critically ill children.



Objectives:

The purpose of this quality improvement project was to describe the current state of movement practices in a quaternary-level PICU and to develop, implement and test the feasibility of an EM program using an interprofessional team approach.



Methods:

A focus group was conducted with frontline nurses, physiotherapists, respiratory therapists and physicians to understand the current movement practices in the PICU. We conducted a root cause analysis to determine factors contributing to inconsistent movement practices.

Using the Plan-Do-Study-Act method, an interprofessional EM algorithm (see attached) was implemented. The algorithm incorporated structured EM rounds to assess and create a customized movement plan for each child based on five levels of movement. Levels were determined by the amount of assistance required to get out of bed (OOB) and included five domains: positioning, limb movements, sitting/transferring, weight-bearing and functional movement. Regular focus groups were held until a sustainable approach to EM was reached. Data collected included baseline movement level, daily movement levels, length of time to first move OOB, adherence to movement plans as well as barriers to movement.

Results:

Eighty-one patients were assessed for EM during the five weeks of the project (total of 375 patient movement assessments). Approximately 8% of the time, patients were not assessed secondary to imminent discharge from the PICU or they were palliative. With an average daily census of 17, EM rounds took 15-25 minutes. In 36% of assessments, children were deemed not ready to move OOB, in 46% of assessments, children required maximum assistance to move OOB (80% were moved), and for 18% of assessments (55% were moved) children were deemed safe to move OOB with minimum to moderate assistance.

Time to first move OOB was as follows: 19% within 24 hours, 20% within 48 hours, 8% within a week, 11% after one week, and 42% did not get OOB before discharge from the PICU. Reasons children did not get OOB were: medically not ready (28%), equipment issues (19%), having a procedure (18%), inadequate personnel (7%), patient/parent refusal (7%), unclear activity orders (5%), safety risk for loss of line/tube (5%), provider knowledge gap (5%), no reason provided (5%). There were no reported adverse safety events attributable to movement during the implementation period.

Of frontline health care providers, 80% felt the EM Program was additive and not duplicative of other efforts and 75% perceived it as an efficient strategy to aid in movement planning for their patient(s).

Conclusion:

This project demonstrated that it is feasible to implement an interprofessional EM program in a quaternary-level PICU. Evaluation of this program has helped to guide resource utilization and further process development to provide an approach to consistent EM of critically ill children in the PICU. Further steps will include demonstrating the impact of EM on markers of morbidity and LOS.



References:
  1. Adler J, Malone D. Early mobilization in the intensive care unit: A systematic review. Cardiopulm Phys Ther J. 2012; 23(1): 5-13.
  2. Smeets I, Tan E, Vossen H, et al. Prolonged stay at the paediatric intensive care unit associated with paediatric delirium. Eur Child Adoles Psy. 2010; 19: 389-93.
  3. Banwell B, Mildner R, Hassal A, et al. Muscle weakness in critically ill children. Neurology. 2003; 61: 1779-82.
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