Hi, my name is Sapnika Chadkar. I'm the Vice Chair of Pediatric Anesthesiology and Critical Care Medicine at the Johns Hopkins University School of Medicine. I'm thrilled to talk about early mobility and exercise. As I like to call it, illness doesn't mean stillness. Let's get started. If you're looking for one-stop shopping for all things, PICU and NICU liberation literature, please go to bit.ly backslash peds liberation literature, where I curate daily any content related to the ABCDEF bundle in pediatrics. We're here to talk about early mobility in critically ill children. Fortunately, we know what the landscape of mobility across the world is in pediatric intensive care units, including the United States, the EU, and Canada. The prevalence of acute rehab for kids in the PICU study or PARC-PICU included 82 pediatric intensive care units or pediatric cardiac intensive care units across the United States and 1,800 patients. What we found in US PARC-PICU was a wake-up call. On any given day in pediatric ICUs across the country, one-fifth of children were completely immobile and did not move from their bed. Additionally, girls and younger patients were less likely to receive PT or OT provided mobility and patients with higher baseline function were at risk for a delayed PT or OT consult. Now, hot off the press, we finally have the 2022 SCCM clinical practice guidelines focused specifically on pediatric patients with regards to pain, agitation, neuromuscular blockade, delirium, and consideration of the environment and early mobility. However, we have a lot of work to do. In our analysis of 161 PICUs across 18 countries, early mobility initiatives were the least likely to be implemented in these ICUs of all of the ABCDEF bundle elements. We essentially have created a culture of immobility. The question is, why? Well, liberation is not a new concept. I love this quote from JAMA in 1899. It means a great deal to be put on their own feet in a short time rather than be confined to bed having their weak backs and general debility increase rather than disappear after the operation which was to cure them. Dr. Emil Reyes, JAMA, 1899. JAMA 1944. I love this title. The abuse of rest as a therapeutic measure in surgery. Prolonged bed rest is anatomically and physiologically unsound. Early restoration of medical and surgical patients to normal life is an essential feature of modern convalescent supervision. In 1998, Thomas Petty, one of the fathers of adult pulmonary medicine said, what I see these days are sedated patients lying without motion, appearing to be dead except for the monitors that tell me otherwise. By being awake and alert, they could interact with family, feel human, and sustain the zest for living, which is a requirement for survival. Where do we go from here? How do we negotiate making sure that we sustain the zest for living, which is a requirement for survival with our culture of immobility in pediatric intensive care units? Well, we decided to tackle that back in fall of 2013 at Johns Hopkins. We realized that our culture of immobility was likely due to a variety of different factors, including over sedation, rapid escalation of drugs, PT and OT being an afterthought, not being called until all of the acute resuscitative measures had been addressed. Restraints were the rule and not the exception. We weren't talking about delirium at all. Benzos and Benadryl were being used to improve sleep and family were simply observers in the process. In this conceptual framework, I decided that immobility is really related to all of these different factors and that they have significant impact on patients and families, similar to post-intensive care syndrome in pediatrics. We know mobility has many benefits. Blood sugar, homeostasis, cardiovascular and pulmonary function, sleep-wake patterns, cognition, having a positive impact on the risk for depression. We knew that we had some culture change goals that we needed to make. Every kid, every day. We couldn't put in place an initiative that was only intended for one specific patient population. We needed to get the experts to the bedside early. No child was ever too sick to turn away a PT or an OT or an SLP. We wanted to focus on analgesia first and then sedation only if needed. Kids and families can tell us what they need. Finally, sleep hygiene and delirium prevention mean more mobility. Contrary to popular belief, we did not receive any financial resources initially when we implemented Pick You Up. It was completely the cost of multi-professional collaboration to promote culture change. All of these champions from each of these professions got in a room together and decided they wanted to make a difference. We came up with a cool name that was the very first step, a name that everyone could rally behind and utilize as our shared mission. We used the translating research into practice model or the TRIP model for our quality improvement initiative. It's very important to note that I had never performed a QI project or led a QI project in my career. This was my first one. This model made it very easy for me to learn the process along with my team to guide us all together. First, we needed to summarize the evidence, then identify local barriers to implementation, measure our performance, and finally ensure that all patients receive the interventions. We performed a very simple literature review because there wasn't much out there. We found that EM at the time was safe and feasible in all of these studies, in a very heterogeneous patient population, but it gave us the green light to move forward. When Pick You Up was born, it was a structured and interdisciplinary program. We wanted it to be integrated into the routine care of every critically ill child in our unit. Obviously, we wanted our outcomes to improve from a standardized mechanism to increase activity level to lowering rates of mobility-associated complications, decreasing length of mechanical ventilation, and decreasing length of stay. It was very, very important, and for all of you, this is very important as you're implementing your own initiatives, that you make it clear to your team that ambulation is not the goal for everyone. Mobility is progressive, and every day may be different. For the most critically ill child on an oscillator, on multiple infusions, normalization of the sleep-wake pattern may be the most important thing we can do, opening the shades, making sure they have quiet at night, and hear voices during the day. And then over time, we can get to their baseline functional activities, which we know in the PICU is very different for each and every child. We had a shared mental model called the PICU Up Levels, which gave us all the same framework to work with, with regards to critical illness and what that meant for the activities. And these are all in the PCCM paper in 2016. Sleep is a major priority, because if you don't sleep well at night, you're not going to mobilize during the day. So this is key for our Level 1, our sickest patients. And over time, you can see everyone got a note to your PT consult by day three. Everyone was getting screened for delirium Q12. And then over time, activities progressed as patients become less critically ill. Sedation was one of our major challenges, and I bet it is for many of you. It was clear that we were approaching sedation often from our comfort levels and not necessarily for our patients. So we started to standardize our approach to administering sedation and making sure the indications were clear. And this was one effort that we made for PRNs, which often are a major culprit in escalating doses for children, especially when many PRNs are given. We had an online module for all of our PICU staff that focused on progressive mobility so that everyone, again, had the shared mental model of what PICU means. So what were our results? This was our first QI single-center study. We found that 82% of patients had a PT session before they got discharged from the PICU and that the median number of mobilization events doubled from three to six. We had 0% adverse events, and that was very important to demonstrate that it was safe. And ET tube ambulation increased from zero to 10%. And before we knew it, more and more studies started coming out looking at early mobility in pediatric ICUs. So in this talk, we by no means are going to be comprehensively presenting all of the different initiatives, but know that there are many studies out there in many different populations, including this one in the Oncocritical Care Unit at St. Jude. Three years later, how are we doing? Well, we asked our staff, what does PICU-UP mean? And how has it impacted our care? And what are your perceptions of it this far out? And what we found was, overall, there was a lot of positive perceptions of PICU-UP with regards to patient and family satisfaction, improved morale in the ICU, and communication. So what did this mean three years later? Well, we decided to ask our staff, what does PICU-UP mean to you? And we found that the things that made PICU-UP successful are having a greater focus on sleep hygiene, setting sedation goals, sharing successes and evidence, generating staff buy-in, and starting small. And we'll show you some examples of that. We had our staff tell us that it improved morale in the PICU, which we originally thought it would actually increase burden. But in fact, it improved morale seeing kids mobilizing and sustaining the zest for living, which is a requirement for survival. Inconsistency with plans was a major barrier and challenge, and heterogeneity in patient developmental levels. But we had some things that we could do to continue to improve. And one of our major projects now is learning about simulation of mobility and implementing simulation for our nurses, who are the cornerstone of mobility, as I'll show you shortly. So we created a culture of mobility. We had success. We were starting to see more kids up and moving, awake and alert during the day with normal day-night cycles. So we mentioned Park PICU and some of the key findings here, including that parents being present at the bedside plays a major role in promoting mobility and having the right mobility protocols, which makes sense. And again, it's the invasive devices that often have the biggest impact in terms of being barriers. And most importantly, early mobility was safe. Only 4% of the 4,700 mobility events that we collected resulted in any change in mostly transient changes in vital signs. Another very important point here is that 62% of all the patients in Park PICU were under the age of three. So we are taking care of children when they are not just in need of rehabilitation, but in need of habilitation. They are actively developing in front of our eyes. And so mobility is a key component of that. Nurses and families are the cornerstone of PICU mobility. The vast majority of these activities are conducted by families, and we have to remember that and give them the resources that they need in order to conduct these activities safely. And to that point, Jessica LaRosa, one of our PICU fellows and soon to be faculty at Johns Hopkins in our pediatric ICU, showed that among all of those activity events that were documented in Park PICU, the only clinical factor associated with the safety event was a delirium screen that was either positive or not done. Positive delirium screen or not done. So again, the ABCDF bundle, it all goes together. Activities on the study day, 4,700. Only 4%, as I mentioned, had any potential safety event. And there were seven displaced feeding tubes, no arrests, and no falls. So what's next? You might say, OK, we're early mobility safe. That's great. It seems to be a good thing. But what about the outcomes? Well, we're starting to study that. So we have a stepped wedge trial that is currently ongoing. This is an NIH R01. You can learn more from clinicaltrials.gov if you just Google PICU up. These are the 10 sites that are involved in the study. Many of these faces will be very familiar to you, including John Birkenbach, who's one of the key authors of the SCCM guidelines for the ABCDF bundle. These are the 10 sites that are participating in the PICU up trial. And many of these faces will look very familiar to you, including one of our moderators for this session. So here we are. Are we letting kids be kids? Are we helping them to sustain the ZISP for living, which is a requirement for survival? Well, I'll let you be the judge. This is our first case, another example of starting low and going slow. A two-year-old after her first day of school and going slow. A two-year-old after a Fontan post-op day one. And normally this child would be sitting in a room probably immediately after her surgery. But we decided to PICU up and Sydney wasn't having it. She threw a full-on tantrum in the middle of the hallway. And you can't blame her. Look at all of the invasive devices that she's tethered to. Chest bulbs, a fresh sternotomy wound, an IJ line, an arterial line. And we found that a little creativity could overcome toddler spirit because her parents said she came into the operating room in a little cozy coupe car. Can we find one of those? And this is what ensued. You're doing so great. Notice she's wearing her sandals. A little piece of home can go a long way. And she went around our unit exactly four times, a 40-bed unit. This was the first child that we ambulated in our unit. As I mentioned, ambulation is not the goal for everyone, but for some patients it's possible. So she's a nine-year-old with alveolar rhabdomyosarcoma. We made a no-benzo sign at her bedside given the risk of benzodiazepines and delirium. Gave her a low-dose morphine PCA to control her own pain. And she walked to the playroom, played with some Barbies. And we celebrated the success. This was the first time we had done this. And before we knew it, it became more common. So you might ask, what about our youngest patients? Well, as your culture changes, it's possible to do the most that we can for even the little babies. And it may not be possible for every baby, depending on their level of critical illness, but babies can be lucid. Toddlers can be lucid with an endotracheal tube if we address their pain and we use comfort measures. Often, hashtag therapeutic cuddles are the highest level of mobility that an infant or toddler can engage in. And even for the most critically ill infant, like this little one, being in mom's arms is the most important thing that we can facilitate. We have patients on ECMO who are riding tricycles. You can see she has a prosthesis. She's had severe burns. And this ECMO circuit is riding behind her. And remember, safety first. Always wear a helmet. So what should you take away from this talk? Well, the key is that it is never too early to begin to think about mobilizing and liberating the critically ill child. Liberation begins the moment a child enters the hospital and continues until the moment they leave. So post-intensive care syndrome is also an important consideration with post-hospital care syndrome. We have to value each other's expertise. I cannot tell you how much I've learned from my interprofessional colleagues. And we're at the SCCM Congress, and that's the essence of what SCCM does is interprofessional collaboration. And that's what we need to do for early mobility. Consistency is key. Asking each and every day, what is this child's minimum activity goal? What can we make happen given the circumstances and the acuity of the unit? We can't hit the easy button anymore. We need to think about what's best for our patients and their routines. Analgesia first, and then consider sedation if needed. With any pharmacologic therapy, starting low and going slow is key because children do become tolerant and dependent, and that can have a major negative impact on their ability to mobilize. And finally, we must push the envelope safely. We can always do more if we have the right resources and staff and expertise, but doing it safely is the most important thing. Celebrate all successes, big and small, because we have so much work to do. And this is a cake that we bought after our first six months of Pick U Up. And we continue to find different ways of celebrating, whether it's a little swag, just to make sure that people know how appreciated they are for the hard work they do. And that is a key component of implementation. If you need more inspiration and ideas, I encourage you to check out our Twitter page at Pick U Up and Instagram at Hopkins Pick U Up. Thank you very much and good luck implementing your own early mobility programs. Reach out anytime. Thank you.

early mobility

immobility

pediatric ICUs

2022 SCCM clinical practice guidelines

Pick U Up program