Early Rehabilitation in Critically ill Children: A Two Center Implementation Study.

Abstract

OBJECTIVES:

To implement an early rehabilitation bundle in two Canadian PICUs.

DESIGN AND SETTING:

Implementation study in the PICUs at McMaster Children's Hospital (site 1) and London Health Sciences (site 2).

PATIENTS:

All children under 18 years old admitted to the PICU were eligible for the intervention.

INTERVENTIONS:

A bundle consisting of: 1) analgesia-first sedation; 2) delirium monitoring and prevention; and 3) early mobilization.

MEASUREMENTS AND MAIN RESULTS:

Primary outcomes were the duration of implementation, bundle compliance, process of care, safety, and the factors influencing implementation. Secondary endpoints were the impact of the bundle on clinical outcomes such as pain, delirium, iatrogenic withdrawal, ventilator-free days, length of stay, and mortality. Implementation occurred over 26 months (August 2018 to October 2020). Data were collected on 1,036 patients representing 4,065 patient days. Bundle compliance was optimized within 6 months of roll-out. Goal setting for mobilization and level of arousal improved significantly (p < 0.01). Benzodiazepine, opioid, and dexmedetomidine use decreased in site 1 by 23.2% (95% CI, 30.8-15.5%), 26.1% (95% CI, 34.8-17.4%), and 9.2% (95% CI, 18.2-0.2%) patient exposure days, respectively, while at site 2, only dexmedetomidine exposure decreased significantly by 10.5% patient days (95% CI, 19.8-1.1%). Patient comfort, safety, and nursing workload were not adversely affected. There was no significant impact of the bundle on the rate of delirium, ventilator-free days, length of PICU stay, or mortality. Key facilitators to implementation included institutional support, unit-wide practice guidelines, dedicated PICU educators, easily accessible resources, and family engagement.

CONCLUSIONS:

A rehabilitation bundle can improve processes of care and reduce patient sedative exposure without increasing patient discomfort, nursing workload, or harm. We did not observe an impact on short-term clinical outcomes. The efficacy of a PICU-rehabilitation bundle requires ongoing study. Lessons learned in this study provide evidence to inform rehabilitation implementation in the PICU setting.

• Authors: Karen Choong, Douglas D Fraser, Ahmed Al-Farsi, Saif Awlad Thani, Saoirse Cameron, Heather Clark, Carlos Cuello, Sylvie Debigaré, Joycelyne Ewusie, Kevin Kennedy, Michelle E Kho, Kimberley Krasevich, Claudio M Martin, Lehana Thabane, Jasmine Nanji, Catharine Watts, Andrea Simpson, Ashley Todt, Jonathan Wong, Feng Xie, Michael Vu, Cynthia Cupido, Canadian Critical Care Trials Group
• Journal: Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies (Pediatr Crit Care Med) Vol. 25 Issue 2 Pg. 92-105 (Feb 01 2024) ISSN: 1529-7535 [Print] United States
• PMID: 38240534 (Publication Type: Journal Article)
• Copyright: Copyright © 2024 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.

Chemical References

• Dexmedetomidine

Topics

• Child
• Humans
• Adolescent
• Dexmedetomidine (therapeutic use)
• Critical Illness (therapy)
• Canada
• Pain (drug therapy)
• Delirium (prevention & control)
• Intensive Care Units, Pediatric