Background
The paediatric intensive care unit is a stressful environment for critically ill children. To provide safety, comfort, and hemodynamic stability, children are often sedated and considered too sick to be mobilized [
1]. However, immobility is associated with adverse effects such as muscle weakness [
2,
3], pressure ulcers [
4,
5], increased risk of a delirium [
6], and post-intensive care syndrome [
7‐
9]. Ideally, sedation is targeted to facilitate ICU procedures while keeping the patient comfortable without anxiety and agitation.
Early mobilization of patients in adult ICUs has proven feasible and safe with favourable clinical outcomes including decreased delirium incidence and duration of ICU stay, less sedatives consumption, and improved muscle strength and functional status [
6,
10]. Early mobilization in critically ill children undergoing active neurocognitive and physical development is understudied. An early mobilization project in the USA targeting critically ill children showed promising results with no adverse events [
11]; this interdisciplinary approach doubled the number of mobilization events per patient.
A recent point prevalence study of physical rehabilitation in United States PICUs (PARK-PICU: Prevalence of Acute Rehabilitation for Kids in the PICU) demonstrated that younger children and those with higher baseline function were less likely to receive therapist-provided mobility [
12]. In view of the lack of similar data in European countries, we adapted the PARK-PICU study in Europe to determine the prevalence of routine mobilization of children admitted to a PICU for at least 72 h. Additionally, we explored patient-related barriers and potential adverse events related to PICU mobilization.
Discussion
This study presents the first estimates of routine mobilization practices in European PICUs. Mobilization did not occur on 25% of the study days, and when mobility did occur, it was facilitated mostly by nurses alone. Older children and children with severe disability most frequently received mobilization interventions provided by a physical therapist or occupational therapist with the help of nurses. One quarter of the patients were not mobilized at all due to cardiac instability, oversedation, or medical contraindication. We found that the rate of potential safety adverse events (6%) was low relative to the large number of mobility events and similar to that reported in paediatric (4%) and adult (3%) studies [
20]. Most of these potential safety events were transient vital sign changes. Only 0.2% of all mobility events were associated with dislodgement of a device, comparable to the 0.6% rate in adults [
20]. Therefore, our data, in parallel with evidence from single-centre PICU studies [
21,
22], suggest that mobilization of PICU patients is safe.
There are several important similarities and differences with the USA-PARK-PICU findings [
12], a retrospective Canadian multicentre PICU study [
23], and adult point prevalence studies of ICU mobilization practices [
18]. Our observation of a 39% prevalence of therapist-provided mobility on the study days is consistent with the USA data (35%) and the Canadian study (30%) [
23]. However, there was a large difference between the central European and northern and southern countries. A lower proportion of EU-PICUs (16%) reported a unit-based mobility or rehabilitation protocol compared to the USA (27%). The minority of units with systematic mobility approaches may in part explain the moderate prevalence of mobilization interventions provided by a physical therapist or occupational therapist. Integrating PTs and OTs into routine PICU care is integral to advancing infant and toddler’s cognitive and physical development, especially important given that 70% of all PICU patients were < 3 years of age [
24,
25]. Notably, mechanically ventilated children were less likely to receive therapist-provided mobilization, in line with point prevalence studies in adults but different from USA-PARK-PICU where there was no significant difference [
18,
26‐
28].
Our study highlights the crucial role of nurses in mobilization of critically ill children. Nurses are a constant presence at the bedside, so it is not surprising that they provided the majority of mobilization events. In both the USA-PARK-PICU study and USA ARDS-Net point prevalence study in adults, nurses facilitated two thirds of mobility events [
12,
18]. PICU nurses understand the importance of early mobilization but may consider it as additional workload which may translate to lower prioritization [
29]. A strong collaboration with therapists, unit-based protocols in place, and facilities and equipment for mobilization could facilitate the implementation of early mobilization in daily practice [
30]. Although it would be a challenge for many PICUs with nursing shortages to accommodate such changes in practice, there may be a great benefit to patients with shorter PICU stays and duration of mechanical ventilation, less delirium, and reduced costs as has been observed in adults [
31].
Presence of family was very strongly associated with increased out-of-bed mobility in our study. While the USA-PARK-PICU study observed that family presence was positively associated with mobility in children under 3, our European data magnifies this association powerfully. It is likely these family members provided assistance to facilitation success with the mobilization procedure. Parents indeed have a uniquely supportive role during physiotherapy that clinicians cannot provide [
32,
33] which can help to decrease the child’s anxiety and increase buy-in to participate [
34]. With family visitation restrictions heightened during a global pandemic such as COVID-19, strategies are urgently needed to ensure that mobility is not negatively impacted.
Professional and organizational issues such as time constraints, lack of resources to implement early mobilization, and factors related with invasive devices and patient characteristics could be barriers to early rehabilitation across all ICU populations [
35]. Our study show that decreased out-of-bed mobility of patients with an endotracheal tube and invasive devices in place is consistent with finding from adult studies and USA-PICU data. However, a unique finding of the present study, similar to the USA, was that an indwelling urinary catheter was a barrier to out-of-bed mobility. Daily review of the potential for devices to be removed can both reduce the risk of hospital-related infections and avoid confining patients to bed. Out-of-bed mobility can be safe, when a device is secured during the pre-mobility planning [
36], especially if a dedicated multi-professional mobilization protocol and trained team are available. Other perceived barriers to out-of-bed mobility included medical status, lack of physician order, isolation precautions, and oversedation. Having a mobilization protocol in place would, however, not be sufficient to overcome all these kinds of barriers. A culture change among PICU team is warranted.
Our study has several limitations. First, only PICUs with sufficient research staffing or interest in early mobilization may have participated, potentially biasing the results to overestimate mobilization practices. Still, this risk is low because only 16% of the participating PICUs had a formal protocol. Second, mobility assessments were unblinded, which may have led to greater mobility delivery on the study days. Efforts had been made to limit knowledge of the study, and the observed relatively low prevalence makes it unlikely that single-day escalation of mobility efforts has biased the overall estimates. Third, we were not able to report whether a patient was medically able to be mobilized or get out of bed. Fourth, combining PT- and OT-provided mobility as the primary outcome may not recognize their unique contributions. But, due to small numbers of OT-provided mobility, we were not able to provide discipline-specific mobility associations. Further, in lack of knowing the proportion of PTs/OTs who work exclusively in the PICU, we could not analyse the difference in therapist-provided mobility between those who work exclusively in the PICU and those who not. Finally, data of non-participating PICUs were not available, thereby limiting the generalizability of the results. Although a remarkable number of 38 PICUs from 16 European countries was involved in this study, the number of participating PICUs per country differed greatly, with the strongest representation of PICUs from Northern Europe. In view of the regional differences, the results of this study should be interpreted with caution. Further, France, one of the biggest European countries with many PICUs, was not represented in this study. There may be additional cultural differences in PICU practices across Europe, and the study findings cannot be considered a true representation of all PICUs in Europe.
Acknowledgements
PARK-PICU EU Collaborators: Paul C. Ritson MCSP, Alder Hey Children’s NHS Foundation Trust, Liverpool UK; Filippia Nikolaou MD, Children Hospital ‘P & A' Aglaia Kyriakou, Athens Greece; Marjorie de Neef RN MSc, Amsterdam UMC, Emma Children’s Hospital, Amsterdam, The Netherlands; Martin Kneyber MD PhD, Beatrix Children’s Hospital, Groningen, The Netherlands; Kate Penny-Thomas RM, Birmingham Women & Children’s Hospital, Birmingham, UK; Christina Linton, Bristol Royal Hospital for Children, Bristol UK; Reinis Balmaks MD, Children’s Clinical University Hospital, Riga, Latvia; Matthias Richter MD, Universitätsklinikum Carl Gustav Carus Klinik für Kinder- und Jugendmedizin, Dresden, Germany; Fabrizio Chiusolo MD, Children’s Hospital Bambino Gesù – PICU, Rome, Italy; Corrado Cecchetti MD, Children’s Hospital Bambino Gesù - Emergency Department PICU, Rome, Italy; Marco Roberti MSc RN, Children’s Hospital Bambino Gesù -CICU, Rome, Italy; Michela Di Furia MSc RN, Children’s Hospital Bambino Gesù – Palidoro, Italy; Chantal Grandjean RN MSc, Lausanne University Hospital (CHUV), Lausanne, Switzerland; Bettina Nygaard RN PhD, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Yolanda Lopez MD, Cruces University Hospital, Bilbao, Spain; Tolga Koroglu MD†, Dokuz Eylül University, Izmir, Turkey; Tolga Besci MD, Dokuz Eylül University, Izmir, Turkey; Roberta Da Rin Della Mora RN PhD, IRCCS Istituto Giannina Gaslini, Genova, Italy; Rachel S Agbeko MD PhD, Great North Children’s Hospital, Newcastle upon Tyne, UK; Emma Borrows MD, Great Ormond Street Hospital, London, UK; Nathalie Bochaton MSc, Geneva University Hospital (HUG), Geneva, Switzerland; Janet Mattsson RN PhD, Karolinska, Stockholm, Sweden; Anne Ksellmann MD, Kinderherzzentrum Sankt Augustin, St Augustin, Germany; Barbara Hero RN, Children’s University Hospital Cologne, Köln, Germany; Jowita Rosada-Kurasinska, Department of Pediatric Anesthesiology and Intensive Therapy, Poznań University of Medical Sciences, Poznań, Poland; Magdalena Świder MD, Kliniczny Szpital Wojewódzki No 2 w Rzeszowie, Rzeszów, Poland; Amabile Bonaldi RN, Ospedale Maggiore, Verona, Italy; Cristina Giugni MD, Meyer Children’s Hospital, Florence, Italy; Siva Oruganti MD, Noah’s Ark Children’s Hospital for Wales, Cardiff, UK; Simon Gates PT MSc, Nottingham Children’s Hospital and Neonatology, Nottingham University Hospitals NHS Trust, Nottingham, England; Hazel Smith RM PhD, Children’s Health Ireland at Crumlin, Dublin, Ireland; Annelies van Zwol MD PhD, Radboudumc-Amila Children’s Hospital, Nijmegen, The Netherlands; Jenna Hills PT, Royal Hospital for Children, Glasgow, Scotland; Johanna Conroy PT, Royal Manchester Children’s Hospital, Manchester, England; Mark Bebbington MD, Royal Stoke University Hospital, Stoke-on-Trent, UK; Felix Neunhoeffer MD PhD, Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children’s Hospital Tübingen, Tübingen, Germany; Els Duval MD PhD, UZA Antwerp, Belgium.
Ko Hagoort MA, Erasmus MC, for editing the manuscript.
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