PICU Early Mobilization and Impact on Parent Stress

Stressful Experiences of Parents in the Paediatric Intensive Care Unit: Searching for the Most Intensive PICU Stressors

Hospitalization of a child in the paediatric intensive care unit (PICU) is extremely stressful, both for the child and for his or her family. The purpose of this study was to gain deeper insight into the stressful experiences of parents of children hospitalized in the PICU. This study included 96 parents. The data were collected using a translated and standardized scale "The Parental Stressor Scale: Paediatric Intensive Care Unit (PSS: PICU)". This study confirms high exposure of parents to numerous PICU stressors. The most intense PICU stressor for parents was child's breathing depending on the ventilator (4.22 ± 1.17), and the least intense was child's demanding behaviour (1.17 ± 0.33). A significant positive correlation between the level of parents' perceived stress and the number of their children was recorded (r = 0.240, p = 0.02), while there was no significant correlation between the level of stress and other sociodemographic variables. A significantly higher level of stress was experienced by parents with primary school education (p = 0.032) and parents who are not healthcare professionals (p < 0.01). It is necessary to establish a system that will enable continuous assessment of parents' stress levels and timely prevention of stressful experiences for parents in the PICU.

Caregiver perceptions of an early mobility and communication protocol in the pediatric ICU

PURPOSE

Early mobility (EM) and patient communication have known benefits for critically ill patients, but perceived barriers exist, notably related to family and caregiver concerns. Caregiver perceptions of an EM and communication therapy protocol in the pediatric intensive care unit (PICU) were assessed.

METHODS

Caregivers of PICU patients at a free-standing academic children's hospital completed a survey using a Likert-type agreement scale on their perceptions surrounding the safety of EM, benefits of EM and communication, and barriers to EM and communication services.

RESULTS

Forty caregivers completed the survey. Most agreed or strongly agreed that EM helped their child get stronger (76%), improved their child's mood (57%), helped them to be involved in their child's care (86%), and improved their child's overall experience (78%). Most disagreed with statements relating to EM causing fear or pain (57%). Caregivers agreed that communication therapy improved overall ICU experience (75%). Free-text comments emphasized meaningful relationships with rehabilitation and unit staff.

CONCLUSION

Caregivers perceived EM and communication interventions as enriching to their child's ICU experience and the majority did not perceive that EM caused fear or pain.

Comfort-holding in critically ill children: a scoping review

PURPOSE

To understand and summarize the breadth of knowledge on comfort-holding in pediatric intensive care units (PICUs).

SOURCES

This scoping review was conducted using PRISMA methodology. A literature search was conducted in MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane CENTRAL Register of Controlled Trials. Search strategies were developed with a medical librarian and revised through a peer review of electronic search strategies. All databases were searched from inception to 14 April 2020. Only full-text articles available in English were included. All identified articles were reviewed independently and in duplicate using predetermined criteria. All study designs were eligible if they reported on comfort-holding in a PICU. Data were extracted independently and in duplicate.

PRINCIPAL FINDINGS

Of 13,326 studies identified, 13 were included. Comfort-holding was studied in the context of end-of-life care, developmental care, mobilization, and as a unique intervention. Comfort-holding is common during end-of-life care with 77.8% of children held, but rare during acute management (51% of children < three years, < 5% of children ≥ three years). Commonly reported outcomes included child outcomes (e.g., physiologic measurements), safety outcomes (e.g., accidental line removal), parent outcomes (e.g., psychological symptoms), and frequency of holding.

CONCLUSION

There is a paucity of literature on comfort-holding in PICUs. This scoping review identifies significant gaps in the literature, including assessment of child-based outcomes of comfort-holding or safety assessment of comfort-holding, and highlights core outcomes to consider in future evaluations of this intervention including child-based outcomes, parent-based outcomes, and safety of the intervention.

Early Mobilization in a PICU: A Qualitative Sustainability Analysis of PICU Up!

OBJECTIVES

To identify staff-reported factors and perceptions that influenced implementation and sustainability of an early mobilization program (PICU Up!) in the PICU.

DESIGN

A qualitative study using semistructured phone interviews to characterize interprofessional staff perspectives of the PICU Up! program. Following data saturation, thematic analysis was performed on interview transcripts.

SETTING

Tertiary-care PICU in the Johns Hopkins Hospital, Baltimore, MD.

SUBJECTS

Interprofessional PICU staff.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Fifty-two staff members involved in PICU mobilization across multiple disciplines were interviewed. Three constructs emerged that reflected the different stages of PICU Up! program execution: 1) factors influencing the implementation process, 2) staff perceptions of PICU Up!, and 3) improvements in program integration. Themes were developed within these constructs, addressing facilitators for PICU Up! implementation, cultural changes for unitwide integration, positive impressions toward early mobility, barriers to program sustainability, and refinements for more robust staff and family engagement.

CONCLUSIONS

Three years after implementation, PICU Up! remains well-received by staff, positively influencing role satisfaction and PICU team dynamics. Furthermore, patients and family members are perceived to be enthusiastic about mobility efforts, driving staff support. Through an ongoing focus on stakeholder buy-in, interprofessional engagement, and bundled care to promote mobility, the program has become part of the culture in the Johns Hopkins Hospital PICU. However, several barriers remain that prevent consistent execution of early mobility, including challenges with resource management, sedation decisions, and patient heterogeneity. Characterizing these staff perceptions can facilitate the development of solutions that use institutional strengths to grow and sustain PICU mobility initiatives.

Prevalence of Acute Rehabilitation for Kids in the PICU: A Canadian Multicenter Point Prevalence Study

OBJECTIVES

To evaluate mobilization practices, barriers, and mobility-related adverse events in Canadian PICUs.

DESIGN

National 2-day point prevalence study.

SETTING

Thirteen PICUs across Canada.

PATIENTS

Children with a minimum 72-hour PICU length of stay on the allocated study day.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Outcomes of interest were the prevalence and nature of mobilization activities, rehabilitation resources, adverse events, and factors associated with out-of-bed mobility and therapist-provided mobility. Two PICUs (15%) had early mobilization practice guidelines, and one PICU (8%) reported a formal process for engaging families in the mobilization of patients. The prevalence of mobilization was 110 of 137 patient-days (80%). The commonest activity was out-of-bed mobility (87/137; 64% patient-days); there was no active mobilization on 46 patient-days (34%). Therapists provided mobility on 33% of patient-days. Mobility was most commonly facilitated by nurses (74% events) and family (49% events). Family participation was strongly associated with out-of-bed mobility (odds ratio 6.4; p = 0.001). Intubated, mechanically ventilated patients were mobilized out-of-bed on 18 of 50 patient-days (36%). However, the presence of an endotracheal tube, vasoactive infusions, and age greater than or equal to 3 years were independently associated with not being mobilized out-of-bed. Barriers were reported on 58 of 137 patient-days (42%), and adverse events occurred in 22 of 387 mobility events (6%).

CONCLUSIONS

Mobilization is common and safe, and the majority of children in Canadian PICUs are being mobilized out-of-bed, even when mechanically ventilated. Family engagement in PICU-based rehabilitation is increasing. This study provides encouraging evidence that common barriers can be overcome in order to safely mobilize children in PICUs.

Postintensive Care Syndrome in Pediatric Critical Care Survivors: Therapeutic Options to Improve Outcomes After Acquired Brain Injury

PURPOSE OF REVIEW

Children surviving the pediatric intensive care unit (PICU) with neurologic illness or injury have long-term morbidities in physical, cognitive, emotional, and social functioning termed postintensive care syndrome (PICS). In this article, we review acute and longitudinal management strategies available to combat PICS in children with acquired brain injury.

RECENT FINDINGS

Few intervention studies in this vulnerable population target PICS morbidities. Small studies show promise for both inpatient- and outpatient-initiated therapies, mainly focusing on a single domain of PICS and evaluating heterogeneous populations. While evaluating the effects of interventions on longitudinal PICS outcomes is in its infancy, longitudinal clinical programs targeting PICS are increasing. A multidisciplinary team with inpatient and outpatient presence is necessary to deliver the holistic integrated care required to address all domains of PICS in patients and families. While PICS is increasingly recognized as a chronic problem in PICU survivors with acquired brain injury, few interventions have targeted PICS morbidities. Research is needed to improve physical, cognitive, emotional, and social outcomes in survivors and their families.