Early Rehabilitation in Critically ill Children: A Two Center Implementation Study
Karen Choong1,2, Douglas D Fraser3, Ahmed Al-Farsi1
1Department of Pediatrics, McMaster University, Hamilton, ON, Canada.
Insights
Implementing an early rehabilitation bundle in pediatric intensive care units (PICUs) improved care processes and reduced sedative use without increasing patient harm. Clinical outcomes were not significantly impacted in this study.
Area of Science:
- Pediatric Critical Care Medicine
- Implementation Science
- Rehabilitation Therapy
Background:
- Pediatric intensive care units (PICUs) often involve prolonged sedation and immobility.
- Early rehabilitation interventions are crucial for improving outcomes in critically ill children.
- Implementing standardized care bundles presents implementation challenges.
Purpose of the Study:
- To implement and evaluate an early rehabilitation bundle in two Canadian PICUs.
- To assess the impact of the bundle on processes of care, safety, and clinical outcomes.
- To identify facilitators and barriers to bundle implementation.
Main Methods:
- An implementation study was conducted in two Canadian PICUs.
- The rehabilitation bundle included analgesia-first sedation, delirium monitoring/prevention, and early mobilization.
- Data on implementation, compliance, safety, and clinical outcomes were collected over 26 months.
Main Results:
- Bundle compliance was achieved within six months; goal setting for mobilization improved.
- Sedative (benzodiazepine, opioid, dexmedetomidine) use decreased significantly at one site.
- No adverse effects on patient comfort, safety, or nursing workload were observed.
- No significant impact on delirium, ventilator-free days, length of stay, or mortality.
Conclusions:
- An early rehabilitation bundle can enhance PICU care processes and reduce sedative exposure safely.
- The bundle did not significantly improve short-term clinical outcomes in this implementation study.
- Further research is needed to confirm the efficacy of PICU rehabilitation bundles.
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.
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