Early mobility in PICU patients
Myron Yaster MD and Sean Barnes MD, MBA
25 years ago, while practicing as a pediatric anesthesiologist/pain consultant and intensivist at the Johns Hopkins Hospital, I like many of my colleagues across the world was struck by the phenomenon of PICU and NICU patients who required extraordinary amounts of sedatives and analgesics while in the ICU, primarily to produce immobility (and prevent accidental tracheal tube and line displacement). Indeed, these young children were receiving doses of midazolam and fentanyl that appeared to almost double daily. Infants weighing less than 10 kg were receiving midazolam doses that would have anesthetized me or at the very least put me into a coma. Why? The conventional wisdom was that this was due to the development of tolerance. Honestly, this just didn’t make any sense to me. I wondered if these patients were in fact delirious and agitated because of the drugs and ICU environment (24 hour lights on, procedures like getting chest x rays in the middle of the night, etc.) prevented them from having restorative sleep? I asked one of our combined pediatric/anesthesia/PICU fellows, Dr. Sapna Kudchadkar, to look into this hypothesis and investigate it as part of her fellowship training and early career development. Little did I know just how complicated a question this was and what a herculean task it would be to answer the question. Sapna went on to get a PhD in the science of clinical investigation. The results of her efforts have been nothing short of spectacular. Sapna and the Johns Hopkins PICU Up! group went on to discover that critically ill children were not sleeping and were indeed, often delirious. Further, the meds we use to produce sedation actually interfered with normal sleep architecture and prevented restorative sleep. Finally, she asked the question, “why do critically ill patients need to be immobilized in the first place?” This led to studies looking at early mobilization in the ICU and ultimately to efforts of the Society of Pediatric Critical Care Medicine to liberate pediatric ICU patients from their beds and to mobilize them early in their hospital course.1,2 A Liberation Bundle was developed and includes 6 elements (ABCDEF) addressing pain assessment and control, sedation management, delirium assessment and management, spontaneous awakening and breathing trials, early mobility, and family engagement.3 Finally, a multicenter study of 8 PICUs implementing the whole liberation bundle and found reduced mortality with increased bundle utilization.4 Today’s PAAD by Dormann et al.5 discusses how one institution, the Medical University of South Carolina, went about instituting this early mobility program in their practice. Finally, there are many take home messages from this article on how to institute a quality improvement and safety study in your practice and the continuing importance of having pediatric anesthesiologists trained in, and participating in, the care of critically ill children. Myron Yaster MD
Original article
Domann JE, Davies LE, Zivick EE, Johnson L, Keller EP, Walz AA. Keep Moving: Sustainability of an Early Mobility Protocol in an Academic Pediatric ICU. Pediatr Qual Saf. 2025 Jan 7;10(1):e783. doi: 10.1097/pq9.0000000000000783. PMID: 39776949; PMCID: PMC11703437.
“Interested stakeholders at the Medical University of South Carolina’s PICU convened a multidisciplinary committee to create the Sleep, Play, Heal (SPH) program, which aimed to implement best practices within the unit. The SPH program’s ultimate goal is to improve our patient population’s functional status and build a culture that supports adherence to the ABCDEF bundle. Although the program involved all areas of the ICU liberation bundle, developing an early mobility protocol was a major focus.”5 Who were the stakeholders? Initially, pediatric intensivists, nurses, respiratory therapists, physical therapists, occupational therapists, speech-language pathologists, pharmacists, and child life specialists. In 2022, it expanded to include patient-family advocates, resident physicians, art and music therapists, and research associates.”5
“A formal ICU mobility protocol was implemented as part of a unit-wide ICU liberation bundle. As part of the ongoing program assessment, over a specific 3-month timeframe annually from 2017 to 2023, the number of physical and occupational therapy (PT/OT) consults, mobilization rate, and time to PT/OT consult were analyzed. In addition, in 2023, we assessed specific barriers to early PT/OT consultation.”5 After instituting the program, what did they find? “Annually, for each study timeframe, there was a sustained decrease in time to therapy consult from a mean of 3.8 days for PT and 7 days for OT in 2017 to 1.9 and 1.6 days, respectively, in 2023. Similarly, the mobilization rate increased from 20.3 sessions per 100 patient days in 2017 to 48.2 in 2023. There was a trend toward missed or delayed therapy consults at times of higher ICU census. No adverse events were associated with mobilization.”5
“This study contributes to the growing body of evidence that early mobilization is safe and feasible by demonstrating a decrease in our unit’s unplanned extubation rate, a key safety measure for mobilizing critically ill patients and recording no serious safety events related to patient mobilization. Further, by examining multiyear program data, our study adds depth to the literature by demonstrating the sustainability of an early mobility protocol.”5
Finally, the authors discuss including therapy teams in a daily multidisciplinary PICU huddle as an opportunity to review mobilization plans for high-risk patients and have a direct team discussion about the need for PT and OT consults for any new patient admissions. Additionally, the authors now have “just in time” rolling education campaign for for all patient stakeholders to encourage utilization of the early mobilization protocol. Future directions include leveraging the electronic records by adding a smart phrase for PT and OT consultation date as a visual reminder to place consults for eligible patients and building an automated PT and OT consult order in the electronic health record on PICU day 3.5
For those of you old timers who trained under the legendary Dr. Jack Downes at the Children’s Hospital of Philadelphia in the 1970s-80s these results are hardly surprising.6 Dr. Downes and his colleagues pioneered early tracheostomy in chronically ill patients and encouraged ambulation and play time as an essential component of long term ICU management.
While this article focuses on implementation of early mobility in the PICU, the most important question for us as pediatric anesthesiologists is...how can WE make a difference and set these children up for success in the perioperative continuum? And how can we optimize early mobility in the pediatric ICU and also on the inpatient floor setting through our approach to anesthetic management? More to come on this topic.
Has your institution joined the PICU Up! bandwagon? What are your thoughts on how to optimize a child’s opportunities for early mobility after surgery? Send your comments to Myron who will post in a Friday reader response.
References
1. Wieczorek B, Ascenzi J, Kim Y, et al. PICU Up!: Impact of a Quality Improvement Intervention to Promote Early Mobilization in Critically Ill Children. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies 2016;17(12):e559-e566. (In eng). DOI: 10.1097/pcc.0000000000000983.
2. Wieczorek B, Burke C, Al-Harbi A, Kudchadkar SR. Early mobilization in the pediatric intensive care unit: a systematic review. J Pediatr Intensive Care 2015;2015:129-170. (In eng). DOI: 10.1055/s-0035-1563386.
3. Smith HAB, Besunder JB, Betters KA, et al. 2022 Society of Critical Care Medicine Clinical Practice Guidelines on Prevention and Management of Pain, Agitation, Neuromuscular Blockade, and Delirium in Critically Ill Pediatric Patients With Consideration of the ICU Environment and Early Mobility. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies 2022;23(2):e74-e110. (In eng). DOI: 10.1097/pcc.0000000000002873.
4. Lin JC, Srivastava A, Malone S, et al. Caring for Critically Ill Children With the ICU Liberation Bundle (ABCDEF): Results of the Pediatric Collaborative. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies 2023;24(8):636-651. (In eng). DOI: 10.1097/pcc.0000000000003262.
5. Domann JE, Davies LE, Zivick EE, Johnson L, Keller EP, Walz AA. Keep Moving: Sustainability of an Early Mobility Protocol in an Academic Pediatric ICU. Pediatric Quality & Safety 2025;10(1):e783. DOI: 10.1097/pq9.0000000000000783.
6. Mai CL, Schreiner MS, Firth PG, Yaster M. The development of Pediatric Critical Care Medicine at The Children's Hospital of Philadelphia: an interview with Dr. John J. 'Jack' Downes. PaediatrAnaesth 2013;23(7):655-664.