Read Full Text: PICU Up!: Impact of a Quality Improvement Intervention to Promote Early Mobilization in Critically Ill Children (Free to access)
Journal: Pediatric Critical Care Medicine
Year Published: 2016
Ranked 81st on our 2015-2020 list of the 100 most influential OT-related articles
We all have ideas about how patient care could be better— but some pretty daunting questions can give us pause:
- How do we actually create change in our complex health systems?
- How do we get everyone on board?
- Where do we even begin?
Spending time in research is the perfect way to approach these big questions, largely because we get to see examples of what it looks like to systematically improve care.
This week, we look at the creation and introduction of an early mobility program in a pediatric intensive care unit (PICU). Not only will you see how the program improved mobility practices for the kids on the unit, you’ll notice how the program elicited increased OT involvement in this type of work.
Plus, you’ll get a sense of what it takes to shift a culture, which can be one of the biggest challenges in any facility.
Let’s dive in.
Brief background on early mobilization in the PICU
The primary purpose of the PICU is ensuring children are medically stabilized. This means addressing organ failure and managing complex disease processes.
Unfortunately, this can lead to children being on bedrest or sedated for prolonged periods of time, which leads to normalizing a culture of immobility.
When children are immobilized for long periods of time, this can have the following implications:
- Short-term and long-term effects on children and their families
- Increased risk of children and youth to develop residual perceptual-motor and socio-emotional problems
- Higher frequency of pressure ulcers
Studies have suggested that interdisciplinary approaches to early mobilization within adult ICUs can lead to shorter hospital stays, improved body function, and decreased isolation, delirium, and use of mechanical ventilation. Pretty impressive!
What was the research question being studied in this trial?
As mentioned earlier, there is a good amount of research demonstrating strong outcomes when adults in the ICU engage in occupational tasks. However, early mobility in children—specifically within the PICU—has not been formally studied as often.
The PICU Up! program was created to evaluate a structured program to help promote early mobility with pediatric patients within an ICU setting.
- The researchers wanted to know how effective this standardized and interdisciplinary program was. Would it increase a child’s safe participation in activities? Would it promote a culture of mobility within an ICU setting?
Who was included in this study?
The program was completed at Johns Hopkins Children’s Center in Maryland, and the study sample included 200 children from 1 day old through 17 years old, all of whom were admitted to the PICU and had a length of stay of at least 3 days. Exclusion criteria included children who had an open chest or abdomen, extracorporeal membrane oxygenation (ECMO), or medical orders specifying other activities are required.
How was the program created?
The PICU UP! program was created using a framework meant to create change in practice using the “four Es,” which are:
- Engage
- Educate
- Execute
- Evaluate
The PICU Up! Initiative had a designated PICU Up! Working Group, which was open to all staff members who wanted to participate. Participating staff members elected at least one champion (basically a leader) who would represent each of the following disciplines: child-life specialists, occupational therapists, speech-language pathologists, physiatrists (rehab physicians), nurses, physicians, and respiratory therapists. These designated individuals met weekly for 18 months to plan (engage and educate) the quality improvement project prior to its implementation.
Together, this core group of leaders identified the current problems and barriers to early mobilization that their pediatric patients faced. Then, they created an activity plan for mobilization based on their respective discipline’s recommendations and evidence-based literature.
If you want to dig deeper into this program and how it was created (or just learn how change happens), watch one of the primary authors discuss the PICU program on an incredible TED Talk.
What did the activity plan entail?
The main intervention was an activity plan, which was based on the diagnoses and clinical conditions of a given child. It focused on improving sleep hygiene, providing routine delirium screening (for all children), and delivering activities tailored to children’s individual needs.
You can see a concise table of the plan on page 11 of the research article. Below are the specific mentions of OT, along with other activities relevant to OT—but I encourage you to look at the table in full to understand the levels and how OT complements the other services:
Level 1 Activities
- Position child in a developmentally supportive position as recommended by OT/PT
- Provide an OT consult in PCU by day 3
Level 2 Activities
- Provide positive touch for infants/toddlers
- Assist child with sitting up in bed three times per day (TID)
- Consider, as a team, encouraging out-of-bed (OOB) activity, such as sitting in a chair and/or ambulation
- Assess need for a daily schedule
Level 3 Activities
- Assist child with OOB activity, such as sitting in a chair, TID
- Ambulate with child twice daily (BID) if core/trunk control allows it
Recommended assessments:
I also wanted to highlight that the plan recommended regular delrium screening for any child who was Level 2 or above.
See the assessments in our OT Assessment Search
How did they roll out the PICU UP! intervention?
The educational portion of the intervention was presented both at in-person meetings and online for all PICU stakeholders. All PICU staff were required to complete online learning modules discussing early mobility, evidence-based literature, and interactive case-based scenarios. All of this incredible information is located in the supplemental digital content within the original article online!
The PICU UP! program even includes a “Rest and Reassess” pocket card. (The content of the card is on page 13 of the article.) You can use it to quickly determine whether you should reconsider early mobility activities in a given session with a PICU UP! patient.
What outcome measures did they track?
Outcome measures were as follows:
- Primary
a. Proportion of patients with OT and/or PT consultations by day 3 in the PICU
b. The number of mobilization activities performed by day 3 in the PICU, such as active range of motion in bed, sitting edge of bed performing an activity, or ambulation - Secondary
a. Number of times activities were stopped, as well as the rationale for doing so
b. Barriers to activities
c. Mobilization-related adverse events, such as accidental line removal
What were the results?
There were some pretty incredible results from this study! Occupational therapy consultations increased significantly between the pre- and post-implementation phases (44% vs 59%).
The median number of mobilization activities per patient doubled from 3 to 6 by PICU Up! day 3, and the proportion of children receiving at least one in-bed activity significantly increased, from 70% to 98%. Pre-implementation of PICU Up!, 15% of all children had ambulated by day 3 of PICU admission. Post-implementation, this number increased to 27%! Regarding children who were orally intubated, none of them were ambulating prior to PICU Up! Following implementation of the program, 4 children ambulated.
Concerning responses from PICU staff, the overall feedback of implementing the PICU UP! program was overwhelmingly positive. 95% of staff indicated the PICU UP! initiative and education were helpful in planning activities, with support from OTs and PTs reported as an invaluable resource for early mobilization.
Some barriers for activities and for implementing the PICU UP! Program were:
- Not having the number of staff necessary to mobilize the child throughout their plan of care
- Some of the practitioners reported the medical team was not as open to discussing mobilization when competing with the demands of the bedside caregivers.
What did the authors conclude/discuss?
The implementation of the PICU UP! program was pretty successful! It created a safe culture of early mobility, and increased the involvement of OTs and PTs within the PICU. There were increases in early mobilization activities among critically ill children, and the PICU UP! program identified several learning opportunities for ongoing modification and education.
Takeaways for OT practitioners
(These are my personal takeaways, and were not mentioned in the article.)
1.) To improve care, it often takes a change in culture— and we are starting to see a blueprint emerge for how this cultural shift actually happens
I was struck when reading this paper by how similar the quality improvement process was to the process we just read about in implementing an OT care pathway for paramedics.
Even though the settings and programs were completely different, the process was really similar. A small group of dedicated individuals held focus groups, and worked hard to get everyone on the same page, and then created pathways for feedback.
I found that reading these articles has demystified how new systems get created. The key element seems to be a team of dedicated individuals, who are willing to put in the work to get everything organized, so the changes can be sustainable.
I loved how one of the lead authors summarized it in her TED Talk:
“In order to forge the future, we had what we needed: we had people, we had energy, and we had passion.”
2.) This program not only creates an opportunity to be function-focused, it also allows us to make activities meaningful and play-oriented
Let’s face it, the culture of ICU therapy is often focused on ROM, strengthening, and basic mobility. But, the previous research we’ve looked at has indicated that focusing on mobility alone isn’t enough to create long-term functional outcomes. It seems like we should couple ICU mobility with functional and meaningful tasks, if we want to make a long-term difference.
So, to me, the best part of this program is that it provides a framework for OTs to facilitate engagement in functional tasks…and it helps to get the whole team on board in the process 
If you watch the TED Talk, Illness shouldn’t mean stillness, you’ll see how the therapists and staff who were part of PICU UP! did an amazing job at making the activities fun and meaningful for the children. The therapists brought in bikes, scooters, Barbie Dolls, and even a full-grown cow—all in the name of making mobility meaningful for the patients!
I’ll leave you with a screenshot from the TED Talk of what this early mobility actually looked like.
(Pictures like this make the hard work involved in changing systems and the culture 1000% worth it!)
(Possibly) Earn CEUs/PDUs for reading this article.
Many of you can receive continuing education credits for reading this article. Here’s a form to help you do it, along with information to help you understand who qualifies.
And, here’s the full APA citation you many need:
Wieczorek, B., Ascenzi, J., Kim, Y., Lenker, H., Potter, C., Shata, N. J., . . . Kudchadkar, S. R. (2016). PICU Up!: Impact of a Quality Improvement Intervention to Promote Early Mobilization in Critically Ill Children. Pediatric Critical Care Medicine, 17 (12). doi:10.1097/pcc.0000000000000983
