Beginning Restorative Activities Very Early: Implementation of an Early Mobility Initiative in a Pediatric Onco-Critical Care Unit.

Saad Ghafoor,Sarah Schwartzberg,Deni Trone,Jennifer Mazur,Haitao Pan,Marshay James,Andrew Elliott,Sarah Bowman,Cynthia Barger,Mary Anne Lenk,Yvonne Avent,Amanda Brown,Sarah Williams,Mandi Dodson,Shilpa Gorantla,Jacqueline Butrum-Sullivan,Kimberly Fan,Kenneth L Pettit,Amanda Curry,Sapna R Kudchadkar,Fang Wang,Morgan Melancon,Leigh Anne Hall,R Ray Morrison,Kristin Canavera,Mary Lorino,J Smith ,L J Parkhurst ,Rebecca R Quillivan ,Jonathan D Burlison ,Michael J Frett ,Jason K Rains

doi:10.3389/fonc.2021.645716

Abstract

IntroductionChildren with underlying oncologic and hematologic diseases who require critical care services have unique risk factors for developing functional impairments from pediatric post-intensive care syndrome (PICS-p). Early mobilization and rehabilitation programs offer a promising approach for mitigating the effects of PICS-p in oncology patients but have not yet been studied in this high-risk population.MethodsWe describe the development and feasibility of implementing an early mobility quality improvement initiative in a dedicated pediatric onco-critical care unit. Our primary outcomes include the percentage of patients with consults for rehabilitation services within 72 h of admission, the percentage of patients who are mobilized within 72 h of admission, and the percentage of patients with a positive delirium screen after 48 h of admission.ResultsBetween January 2019 and June 2020, we significantly increased the proportion of patients with consults ordered for rehabilitation services within 72 h of admission from 25 to 56% (p<0.001), increased the percentage of patients who were mobilized within 72 h of admission to the intensive care unit from 21 to 30% (p=0.02), and observed a decrease in patients with positive delirium screens from 43 to 37% (p=0.46). The early mobility initiative was not associated with an increase in unplanned extubations, unintentional removal of central venous catheters, or injury to patient or staff.ConclusionsOur experience supports the safety and feasibility of early mobility initiatives in pediatric onco-critical care. Additional evaluation is needed to determine the effects of early mobilization on patient outcomes.

Highlights

Children with underlying oncologic and hematologic diseases who require critical care services have unique risk factors for developing functional impairments from pediatric post-intensive care syndrome (PICS-p)
The BRAVE early mobility initiative is a quality improvement (QI) project that was developed with the global aim of improving short- and long-term functional outcomes by decreasing the prevalence and effects of PICS-p in an onco-critical care unit
BRAVE was adapted from the Johns Hopkins PICU Up! early mobility program [30] to meet the needs of our specialty unit

Summary

Introduction

Children with underlying oncologic and hematologic diseases who require critical care services have unique risk factors for developing functional impairments from pediatric post-intensive care syndrome (PICS-p). These interventions may be necessary, they disrupt the sleep-wake cycle, increase delirium, impair immunity, cause catabolism, and lead to other chronic physiologic impairments such as disuse atrophy of lean muscle mass, pressure ulcer formation, worsened pulmonary function and cardiac indices, and insulin resistance [15, 17] These sequelae put patients at risk of pediatric post-intensive care syndrome (PICS-p), a constellation of physical, cognitive, emotional, and social impairments seen in children and their caregivers, even after hospital discharge [14, 18,19,20,21,22,23]. An underlying oncologic diagnosis has been identified as an independent risk factor for acquiring critical carerelated functional and cognitive impairments in pediatric patients [24]

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Discussion

Conclusion