Transforming PICU Culture to Facilitate Early Rehabilitation

Abstract

Children who survive a critical illness are at risk of developing significant, long-lasting morbidities that may include neuromuscular weakness, cognitive impairments, and new mental health disorders. These morbidities, collectively known as post–intensive care syndrome (PICS), may lead to functional impairments, difficulty in school and social settings, and reduced quality of life. Interventions aimed at rehabilitation such as early mobilization, sedation minimization and prevention of ICU-acquired weakness, delirium, and posttraumatic stress disorder may lead to improved clinical outcomes and functional recovery in critically ill children. Acute rehabilitation is challenging to implement in a pediatric intensive care unit (PICU), and a culture change is needed to effect widespread transformation in this setting. Our objectives in this article are to review the evidence on PICS in children and strategies for affecting culture change to facilitate early rehabilitation in the PICU.

Keywords

PICU - early mobility - mobilization - culture change - acute rehabilitation - post–intensive care syndrome - critical illness - pediatric

• References

• 1 Cremer R, Leclerc F, Lacroix J, Ploin D ; GFRUP/RMEF Chronic Diseases in PICU Study Group. Children with chronic conditions in pediatric intensive care units located in predominantly French-speaking regions: prevalence and implications on rehabilitation care need and utilization. Crit Care Med 2009; 37 (4) 1456-1462
• 2 Lawn JE, Kinney MV, Black RE , et al. Newborn survival: a multi-country analysis of a decade of change. Health Policy Plan 2012; 27 (Suppl. 03) iii6-iii28
• 3 Namachivayam P, Shann F, Shekerdemian L , et al. Three decades of pediatric intensive care: Who was admitted, what happened in intensive care, and what happened afterward. Pediatr Crit Care Med 2010; 11 (5) 549-555
• 4 Pollack MM, Holubkov R, Funai T , et al. Relationship between the functional status scale and the pediatric overall performance category and pediatric cerebral performance category scales. JAMA Pediatr 2014; 168 (7) 671-676
• 5 Iwashyna TJ, Cooke CR, Wunsch H, Kahn JM. Population burden of long-term survivorship after severe sepsis in older Americans. J Am Geriatr Soc 2012; 60 (6) 1070-1077
• 6 Bienvenu OJ, Colantuoni E, Mendez-Tellez PA , et al. Depressive symptoms and impaired physical function after acute lung injury: a 2-year longitudinal study. Am J Respir Crit Care Med 2012; 185 (5) 517-524
• 7 Bienvenu OJ, Gellar J, Althouse BM , et al. Post-traumatic stress disorder symptoms after acute lung injury: a 2-year prospective longitudinal study. Psychol Med 2013; 43 (12) 2657-2671
• 8 Herridge MS, Cheung AM, Tansey CM , et al; Canadian Critical Care Trials Group. One-year outcomes in survivors of the acute respiratory distress syndrome. N Engl J Med 2003; 348 (8) 683-693
• 9 Adhikari NK, Tansey CM, McAndrews MP , et al. Self-reported depressive symptoms and memory complaints in survivors five years after ARDS. Chest 2011; 140 (6) 1484-1493
• 10 Hopkins RO, Weaver LK, Collingridge D, Parkinson RB, Chan KJ, Orme Jr JF. Two-year cognitive, emotional, and quality-of-life outcomes in acute respiratory distress syndrome. Am J Respir Crit Care Med 2005; 171 (4) 340-347
• 11 Iwashyna TJ, Ely EW, Smith DM, Langa KM. Long-term cognitive impairment and functional disability among survivors of severe sepsis. JAMA 2010; 304 (16) 1787-1794
• 12 Needham DM, Dinglas VD, Bienvenu OJ , et al; NIH NHLBI ARDS Network. One year outcomes in patients with acute lung injury randomised to initial trophic or full enteral feeding: prospective follow-up of EDEN randomised trial. BMJ 2013; 346: f1532
• 13 Needham DM, Dinglas VD, Morris PE , et al; NIH NHLBI ARDS Network. Physical and cognitive performance of patients with acute lung injury 1 year after initial trophic versus full enteral feeding. EDEN trial follow-up. Am J Respir Crit Care Med 2013; 188 (5) 567-576
• 14 Pandharipande PP, Girard TD, Jackson JC , et al; BRAIN-ICU Study Investigators. Long-term cognitive impairment after critical illness. N Engl J Med 2013; 369 (14) 1306-1316
• 15 Bronner MB, Knoester H, Sol JJ, Bos AP, Heymans HS, Grootenhuis MA. An explorative study on quality of life and psychological and cognitive function in pediatric survivors of septic shock. Pediatr Crit Care Med 2009; 10 (6) 636-642
• 16 Ebrahim S, Singh S, Hutchison JS , et al. Adaptive behavior, functional outcomes, and quality of life outcomes of children requiring urgent ICU admission. Pediatr Crit Care Med 2013; 14 (1) 10-18
• 17 Eliason G, Zakrisson AB, Piehl-Aulin K, Hurtig-Wennlöf A. Physical activity patterns in patients in different stages of chronic obstructive pulmonary disease. COPD 2011; 8 (5) 369-374
• 18 Elliott D, Davidson JE, Harvey MA , et al. Exploring the scope of post-intensive care syndrome therapy and care: engagement of non-critical care providers and survivors in a second stakeholders meeting. Crit Care Med 2014; 42 (12) 2518-2526
• 19 Needham DM, Davidson J, Cohen H , et al. Improving long-term outcomes after discharge from intensive care unit: report from a stakeholders' conference. Crit Care Med 2012; 40 (2) 502-509
• 20 Chelluri L, Im KA, Belle SH , et al. Long-term mortality and quality of life after prolonged mechanical ventilation. Crit Care Med 2004; 32 (1) 61-69
• 21 Dowdy DW, Eid MP, Dennison CR , et al. Quality of life after acute respiratory distress syndrome: a meta-analysis. Intensive Care Med 2006; 32 (8) 1115-1124
• 22 Heyland DK, Groll D, Caeser M. Survivors of acute respiratory distress syndrome: relationship between pulmonary dysfunction and long-term health-related quality of life. Crit Care Med 2005; 33 (7) 1549-1556
• 23 Cheung AM, Tansey CM, Tomlinson G , et al. Two-year outcomes, health care use, and costs of survivors of acute respiratory distress syndrome. Am J Respir Crit Care Med 2006; 174 (5) 538-544
• 24 Herridge MS. Legacy of intensive care unit-acquired weakness. Crit Care Med 2009; 37 (10, Suppl): S457-S461
• 25 Herridge MS, Tansey CM, Matté A , et al; Canadian Critical Care Trials Group. Functional disability 5 years after acute respiratory distress syndrome. N Engl J Med 2011; 364 (14) 1293-1304
• 26 Kress JP, Hall JB. ICU-acquired weakness and recovery from critical illness. N Engl J Med 2014; 370 (17) 1626-1635
• 27 Choong K, Siu K, Al-Harbi S, Clark H, Cheng J, Thabane L. Manual muscle strength testing in critically ill children. Pediatric Crit Care Med 2014; 15 (4, Suppl): 137
• 28 Choong K, Al-Harbi S, Siu K , et al; Canadian Critical Care Trials Group. Functional recovery in critically ill children: the “wee-cover” pilot study. Pediatr Crit Care Med 2015; 16 (4) 310-318
• 29 Banwell BL, Mildner RJ, Hassall AC, Becker LE, Vajsar J, Shemie SD. Muscle weakness in critically ill children. Neurology 2003; 61 (12) 1779-1782
• 30 Hartman M, Lin JC. Functional outcomes for children with severe sepsis: is a “good save” good enough?. Pediatr Crit Care Med 2013; 14 (9) 893-894
• 31 Elison S, Shears D, Nadel S, Sahakian B, Garralda ME. Neuropsychological function in children following admission to paediatric intensive care: a pilot investigation. Intensive Care Med 2008; 34 (7) 1289-1293
• 32 Bone MF, Feinglass JM, Goodman DM. Risk factors for acquiring functional and cognitive disabilities during admission to a PICU*. Pediatr Crit Care Med 2014; 15 (7) 640-648
• 33 Alievi PT, Carvalho PR, Trotta EA, Mombelli Filho R. The impact of admission to a pediatric intensive care unit assessed by means of global and cognitive performance scales. J Pediatr (Rio J) 2007; 83 (6) 505-511
• 34 Knoester H, Bronner MB, Bos AP. Surviving pediatric intensive care: physical outcome after 3 months. Intensive Care Med 2008; 34 (6) 1076-1082
• 35 Als LC, Nadel S, Cooper M, Pierce CM, Sahakian BJ, Garralda ME. Neuropsychologic function three to six months following admission to the PICU with meningoencephalitis, sepsis, and other disorders: a prospective study of school-aged children. Crit Care Med 2013; 41 (4) 1094-1103
• 36 Bronner MB, Knoester H, Bos AP, Last BF, Grootenhuis MA. Posttraumatic stress disorder (PTSD) in children after paediatric intensive care treatment compared to children who survived a major fire disaster. Child Adolesc Psychiatry Ment Health 2008; 2 (1) 9
• 37 Fiser DH, Tilford JM, Roberson PK. Relationship of illness severity and length of stay to functional outcomes in the pediatric intensive care unit: a multi-institutional study. Crit Care Med 2000; 28 (4) 1173-1179
• 38 Rennick JE, Rashotte J. Psychological outcomes in children following pediatric intensive care unit hospitalization: a systematic review of the research. J Child Health Care 2009; 13 (2) 128-149
• 39 Rennick JE, Johnston CC, Lambert SD , et al. Measuring psychological outcomes following pediatric intensive care unit hospitalization: psychometric analysis of the Children's Critical Illness Impact Scale. Pediatr Crit Care Med 2011; 12 (6) 635-642
• 40 Rennick JE, Johnston CC, Dougherty G, Platt R, Ritchie JA. Children's psychological responses after critical illness and exposure to invasive technology. J Dev Behav Pediatr 2002; 23 (3) 133-144
• 41 Nelson LP, Gold JI. Posttraumatic stress disorder in children and their parents following admission to the pediatric intensive care unit: a review. Pediatr Crit Care Med 2012; 13 (3) 338-347
• 42 Rees G, Gledhill J, Garralda ME, Nadel S. Psychiatric outcome following paediatric intensive care unit (PICU) admission: a cohort study. Intensive Care Med 2004; 30 (8) 1607-1614
• 43 Conlon NP, Breatnach C, O'Hare BP, Mannion DW, Lyons BJ. Health-related quality of life after prolonged pediatric intensive care unit stay. Pediatr Crit Care Med 2009; 10 (1) 41-44
• 44 Garcia Guerra G, Robertson CM, Alton GY , et al; Western Canadian Complex Pediatric Therapies Follow-up Group. Quality of life 4 years after complex heart surgery in infancy. J Thorac Cardiovasc Surg 2013; 145 (2) 482-488.e2
• 45 Buysse CM, Raat H, Hazelzet JA, Hop WC, Maliepaard M, Joosten KF. Surviving meningococcal septic shock: health consequences and quality of life in children and their parents up to 2 years after pediatric intensive care unit discharge. Crit Care Med 2008; 36 (2) 596-602
• 46 Buysse CM, Raat H, Hazelzet JA , et al. Long-term health-related quality of life in survivors of meningococcal septic shock in childhood and their parents. Qual Life Res 2007; 16 (10) 1567-1576
• 47 Cunha F, Mota T, Teixeira-Pinto A , et al. Factors associated with health-related quality of life changes in survivors to pediatric intensive care. Pediatr Crit Care Med 2013; 14 (1) e8-e15
• 48 Colville GA, Pierce CM. Children's self-reported quality of life after intensive care treatment. Pediatr Crit Care Med 2013; 14 (2) e85-e92
• 49 Curley MA, Meyer E. Caring practices: the impact of the critical care experience on the family. In: Curley MA, Moloney-Harmon P, , eds. Critical Care Nursing of Infants and Children. Section 1: Holistic Pediatric Critical Care Nursing. 2nd ed. Philadelphia, PA: WB Saunders Company; 2001: 47-68
• 50 Knoester H, Grootenhuis MA, Bos AP. Outcome of paediatric intensive care survivors. Eur J Pediatr 2007; 166 (11) 1119-1128
• 51 Rosenbaum P, Gorter JW. The ‘F-words’ in childhood disability: I swear this is how we should think!. Child Care Health Dev 2012; 38 (4) 457-463
• 52 Farris RW, Weiss NS, Zimmerman JJ. Functional outcomes in pediatric severe sepsis: further analysis of the researching severe sepsis and organ dysfunction in children: a global perspective trial. Pediatr Crit Care Med 2013; 14 (9) 835-842
• 53 Pollack MM, Holubkov R, Funai T , et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network. Pediatric intensive care outcomes: development of new morbidities during pediatric critical care. Pediatr Crit Care Med 2014; 15 (9) 821-827
• 54 Iwashyna TJ. Survivorship will be the defining challenge of critical care in the 21st century. Ann Intern Med 2010; 153 (3) 204-205
• 55 Needham DM, Dowdy DW, Mendez-Tellez PA, Herridge MS, Pronovost PJ. Studying outcomes of intensive care unit survivors: measuring exposures and outcomes. Intensive Care Med 2005; 31 (9) 1153-1160
• 56 Harabin AL, Kiley JP. How the National Heart, Lung, and Blood Institute (NHLBI) develops research priorities and supports critical care research. Phys Ther 2012; 92 (12) 1489-1493
• 57 Milbrandt EB, Eldadah B, Nayfield S, Hadley E, Angus DC. Toward an integrated research agenda for critical illness in aging. Am J Respir Crit Care Med 2010; 182 (8) 995-1003
• 58 Angus DC, Carlet J ; 2002 Brussels Roundtable Participants. Surviving intensive care: a report from the 2002 Brussels Roundtable. Intensive Care Med 2003; 29 (3) 368-377
• 59 Deutschman CS, Ahrens T, Cairns CB, Sessler CN, Parsons PE ; Critical Care Societies Collaborative/USCIITG Task Force on Critical Care Research. Multisociety Task Force for Critical Care Research: key issues and recommendations. Crit Care Med 2012; 40 (1) 254-260
• 60 Calvo-Ayala E, Khan BA, Farber MO, Ely EW, Boustani MA. Interventions to improve the physical function of ICU survivors: a systematic review. Chest 2013; 144 (5) 1469-1480
• 61 Bailey P, Thomsen GE, Spuhler VJ , et al. Early activity is feasible and safe in respiratory failure patients. Crit Care Med 2007; 35 (1) 139-145
• 62 Morris PE, Goad A, Thompson C , et al. Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med 2008; 36 (8) 2238-2243
• 63 Burtin C, Clerckx B, Robbeets C , et al. Early exercise in critically ill patients enhances short-term functional recovery. Crit Care Med 2009; 37 (9) 2499-2505
• 64 Schweickert WD, Pohlman MC, Pohlman AS , et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 2009; 373 (9678) 1874-1882
• 65 Morris PE, Griffin L, Berry M , et al. Receiving early mobility during an intensive care unit admission is a predictor of improved outcomes in acute respiratory failure. Am J Med Sci 2011; 341 (5) 373-377
• 66 Gosselink R, Clerckx B, Robbeets C, Vanhullebusch T, Vanpee G, Segers J. Physiotherapy in the intensive care unit. Neth J Crit Care. 2011; 15 (2) 66-75
• 67 Winkelman C, Higgins PA, Chen YJ. Activity in the chronically critically ill. Dimens Crit Care Nurs 2005; 24 (6) 281-290
• 68 Krishnagopalan S, Johnson EW, Low LL, Kaufman LJ. Body positioning of intensive care patients: clinical practice versus standards. Crit Care Med 2002; 30 (11) 2588-2592
• 69 Stiller K. Safety issues that should be considered when mobilizing critically ill patients. Crit Care Clin 2007; 23 (1) 35-53
• 70 Hodgson CL, Stiller K, Needham DM , et al. Expert consensus and recommendations on safety criteria for active mobilization of mechanically ventilated critically ill adults. Crit Care 2014; 18 (6) 658
• 71 Adler J, Malone D. Early mobilization in the intensive care unit: a systematic review. Cardiopulm Phys Ther J 2012; 23 (1) 5-13
• 72 Kayambu G, Boots R, Paratz J. Physical therapy for the critically ill in the ICU: a systematic review and meta-analysis. Crit Care Med 2013; 41 (6) 1543-1554
• 73 Stiller K. Physiotherapy in intensive care: an updated systematic review. Chest 2013; 144 (3) 825-847
• 74 Hopkins RO, Spuhler VJ, Thomsen GE. Transforming ICU culture to facilitate early mobility. Crit Care Clin 2007; 23 (1) 81-96
• 75 Thomsen GE, Snow GL, Rodriguez L, Hopkins RO. Patients with respiratory failure increase ambulation after transfer to an intensive care unit where early activity is a priority. Crit Care Med 2008; 36 (4) 1119-1124
• 76 Morris PE. Moving our critically ill patients: mobility barriers and benefits. Crit Care Clin 2007; 23 (1) 1-20
• 77 Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. San Francisco, CA: Jossey-Bass Publishers; 1996
• 78 Kotter JP. Leading change: why transformation efforts fail. Harv Bus Rev 1995; 4231: 57-67
• 79 Hopkins RO, Miller III RR, Rodriguez L, Spuhler V, Thomsen GE. Physical therapy on the wards after early physical activity and mobility in the intensive care unit. Phys Ther 2012; 92 (12) 1518-1523
• 80 Carrothers KM, Barr J, Spurlock B, Ridgely MS, Damberg CL, Ely EW. Contextual issues influencing implementation and outcomes associated with an integrated approach to managing pain, agitation, and delirium in adult ICUs. Crit Care Med 2013; 41 (9) (Suppl. 01) S128-S135
• 81 Choong K, Koo KK, Clark H , et al. Early mobilization in critically ill children: a survey of Canadian practice. Crit Care Med 2013; 41 (7) 1745-1753
• 82 Choong K, Foster G, Fraser DD , et al; Canadian Critical Care Trials Group. Acute rehabilitation practices in critically ill children: a multicenter study. Pediatr Crit Care Med 2014; 15 (6) e270-e279
• 83 Zebuhr C, Sinha A, Skillman H, Buckvold S. Active rehabilitation in a pediatric extracorporeal membrane oxygenation patient. PM R 2014; 6 (5) 456-460
• 84 Abdulsatar F, Walker RG, Timmons BW, Choong K. “Wii-Hab” in critically ill children: a pilot trial. J Pediatr Rehabil Med 2013; 6 (4) 193-204
• 85 Choong K, Chacon M, Walker R, Al-Harbi S, Clark H, Al-Mahr G , et al. Early rehabilitation in critically ill children: a pilot study. Pediatr Crit Care Med 2014; 15 (4, Suppl 8): 19
• 86 Choong K, Tran N, Clark H, Cupido C, Corsi D. Acute rehabilitation in critically ill children. J Pediatr Intens Care 2012; 1: 183-192
• 87 Timmerman RA. A mobility protocol for critically ill adults. Dimens Crit Care Nurs 2007; 26 (5) 175-179 , quiz 180–181
• 88 Perme C, Nawa RK, Winkelman C, Masud F. A tool to assess mobility status in critically ill patients: the Perme Intensive Care Unit Mobility Score. Methodist Debakey Cardiovasc J 2014; 10 (1) 41-49
• 89 Odetola FO. Outcomes Research in the PICU. In: Wheeler DS, Wong HR, Stanley TP, , eds. Pediatric Critical Care Medicine. Volume 1: Care of the Critically Ill or Injured Child, 2nd ed. London: Springer-Verlag; 2014: 107-116
• 90 Kanthimathinathan HK, Scholefield BR. Dilemmas in undertaking research in paediatric intensive care. Arch Dis Child 2014; 99 (11) 1043-1049
• 91 Brierley J, Carcillo JA, Choong K , et al. Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine. Crit Care Med 2009; 37 (2) 666-688
• 92 Kudchadkar SR, Yaster M, Punjabi NM. Sedation, sleep promotion, and delirium screening practices in the care of mechanically ventilated children: a wake-up call for the pediatric critical care community*. Crit Care Med 2014; 42 (7) 1592-1600
• 93 Kudchadkar SR, Aljohani OA, Punjabi NM. Sleep of critically ill children in the pediatric intensive care unit: a systematic review. Sleep Med Rev 2014; 18 (2) 103-110
• 94 Latour JM, van Goudoever JB, Schuurman BE , et al. A qualitative study exploring the experiences of parents of children admitted to seven Dutch pediatric intensive care units. Intensive Care Med 2011; 37 (2) 319-325
• 95 Curley MA, Wypij D, Watson RS , et al; RESTORE Study Investigators and the Pediatric Acute Lung Injury and Sepsis Investigators Network. Protocolized sedation vs usual care in pediatric patients mechanically ventilated for acute respiratory failure: a randomized clinical trial. JAMA 2015; 313 (4) 379-389
• 96 Modrykamien AM. The ICU follow-up clinic: a new paradigm for intensivists. Respir Care 2012; 57 (5) 764-772