Discordance between early mobility protocol expectations and nurse-led mobilizations of critically ill children: A...

Early mobility in the pediatric intensive care unit (PICU) is safe and associated with improved cognitive and functional outcomes while reducing complications and hospital length of stay. Protocolized early mobility programs guide activity based on physiologic criteria and increase mobilization rates. However, critically ill children remain under-mobilized. Nurses, key agents of mobility implementation, continue to report barriers even when protocols are in place, yet the extent to which these barriers contribute to deviations from early mobility protocols remains unknown.

To evaluate discrepancies between nurse-reported mobility, electronic health record documentation, and early mobility protocol expectations in the PICU.

We conducted an observational study evaluating nursing-led mobility in 101 patients admitted ≥ 3 days to a large, academic PICU. Key variables included physiologic mobility level (1 = most restrictive to 3 = most liberal), the highest level of mobility (HLM) achieved, and the number of mobilizations. Data were obtained from the electronic health record, end-of-shift nurse interview [registered nurse report (RN-report)], and compared with protocol-expected mobility using Cohen's Kappa. Firth penalized logistic regression assessed age, pediatric risk of mortality score, and pediatric cerebral performance category as predictors of discordance.

Agreement between protocol-expected and RN-reported mobility level was moderate (53.5%; κ = 0.32) and agreement between protocol-expected and RN-reported HLM was poor (40.6%; κ = 0.20). In univariate analysis, mechanical ventilation [odds ratio (OR) = 0.34, 95% confidence interval (CI): 0.19-0.97, P = 0.016], vascular access lines (OR = 0.43, 95%CI: 0.13-0.69, P = 0.043), and sedation > 30 minutes (OR = 0.30, 95%CI: 0.13-0.69, P = 0.005) were associated with reduced odds of HLM discordance. Conversely, severe disability at baseline was associated with higher odds of having a discordant mobility level (OR = 8.33, 95%CI: 2.50-27.76, P = 0.001), and a discordant HLM (OR = 3.71, 95%CI: 1.15-12.01, P = 0.029), even after adjusting for age and illness severity.

In a longstanding PICU mobility program, discordance exists between protocol-expected and RN-reported mobility. Severe baseline disability increases this discordance, highlighting the need to evaluate the fidelity of early mobility programs.