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Adult ICU Liberation Guidelines PANDEM Guidelines for Children and Infants
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Sapna Kudchadkar, MD, PhD “It is a happy talent to know how to play.” – Ralph Waldo Emerson It all started with a name. In 2013, a group of pediatric intensive care unit (PICU) staff at Johns Hopkins Hospital came together for their first official meeting. The agenda was a bit vague. Each discipline was represented: nurses, nurse practitioners, respiratory therapists, physicians, child life specialists, physical therapists (PTs) and occupational therapists (OTs), to name a few. Until then, like our colleagues across the world, we had espoused the normal ICU routine—heavy sedation for intubated patients and bed rest to promote recovery and ensure safety. However, the impact of these practices could not be ignored. We all knew our unit was ready for change. But where to begin? Adult ICU research had shown that minimal and effective sedation, delirium prevention, and early mobilization—key components of the Society of Critical Care Medicine’s (SCCM) ICU Liberation Collaborative—were safe, feasible, and making a difference in outcomes.1 How could we even begin to tackle culture change in a PICU environment defined by heterogeneity in ages (newborn to adult!), diagnoses, and developmental stages? We didn’t know yet. So we spent the entire first meeting brainstorming a name. And “PICU Up!” was born. Once there was a name, it all started to fall into place. The mission: to transform a culture of immobility to a culture of mobility and to do it safely. It was critical to understand everyone’s perspectives, so champions from each discipline went back to their teams and brainstormed barriers and facilitators to culture change. The PICU Up! Task Force met every week for a year to develop a structured and integrated program to promote early mobilization—later joining SCCM’s PICU Liberation Collaborative.2 SCCM’s PICU Liberation Collaborative was comprised of 8 PICU teams who focused on adapting and adopting the ABCDEF Bundle in the PICU setting. There was a focus on the simple things, such as sleep hygiene for everyone, including the highest-acuity patients. Does the TV really need to be on 24 hours a day at any bedside? Is it absolutely necessary to give a baby a bath or weigh the baby at 2 a.m.? Must we get a nonemergent radiograph at 5 a.m.? It all came down to staff convenience—our convenience. We worked together to emphasize the importance of optimizing day-night patterns. Shades up in the morning, sunlight in. Every kid, every day. After all, it’s hard to mobilize a child during the day if the child isn’t experiencing restorative sleep at night. We had to tackle our sedation culture and develop consistent language. Through a focused quality improvement initiative including education for all staff, our unit increased compliance with daily sedation goal-setting to 100%, using the State Behavioral Scale. With the same language, we could use a team-based approach to determine what each child’s unique needs were. “Start low, go slow” became the new routine. Benzodiazepine infusions, which were once first-line treatments for intubated patients, are now the exception, not the rule. Healthy babies without endotracheal tubes cry—so won’t an intubated baby cry too? Good pain control and attention to developmentally appropriate behavior is critical. Starting simple with shared mental models is paramount. As the quest to transform immobility culture took flight, with sleep and sedation at the forefront, delirium prevention and management naturally came into play. Multidisciplinary education, both online and at the bedside, began forward progress, leading to consistent attention to delirium risk factors and treatment. Child psychiatry is now consulted for all children with delirium to ensure appropriate pharmacologic management (after nonpharmacologic approaches have been maximized, of course!) and follow-up once our patients leave the PICU. Once again, multidisciplinary collaboration is the cornerstone to making change happen. So where does the early mobilization part come in? Did we make all these changes and then magically all our patients were up and out of bed walking with their endotracheal tubes? Absolutely not! While the PICU Up! Task Force was excited to get started, there was much trepidation from our staff about what was to come. Was this safe? How can one nurse care for two minimally sedated, intubated children at the same time? How could we make time for mobilization in an already hectic ICU environment? These were all valid and reasonable questions. As such, we had to make small, incremental changes and celebrate every single success. There was a lot of cake! We started with education about what early mobilization actually is—a progression of activities on a spectrum from passive range of motion to ambulation. Each child has a different goal based on his/her premorbid baseline and illness acuity.2 Bed rest orders were no longer the default; instead, the order is “activity as tolerated.” Partnering physicians, including surgeons, provide restrictions if needed but defer to our rehabilitation experts—our PT and OTs—about what is appropriate. Which means bringing PT/OT colleagues to the bedside early. How often do intensivists and nurses defer PTs/OTs or turn them away because children are “too sick”? We found out the answer was often. So we made it our goal to get PT/OT to the bedside by day 3 of PICU admission. While the PICU Up! quality initiative study showed a significant increase in therapy consults by day 3, the most interesting impact was how early PT/OT evaluation and intervention affected mobilization activities facilitated by nurses.2 When therapists are at the bedside early, they partner with nursing staff to determine plans of care, and nurses are then empowered to mobilize patients even with PT/OT isn’t at the bedside. At the crux of all this work is the desire to make sure kids can still be kids, even when they are sick. An intubated 9-year old walking to the playroom to play with Barbies on fentanyl patient-controlled analgesia. A 2-year-old who throws a tantrum when asked to walk, but instead jubilantly uses her little legs to peddle around the 40-bed PICU in a cozy coupe car just 18 hours after cardiac bypass surgery. Taking PICU patients, even with endotracheal tubes and tracheostomies, to watch the fireworks from the top floor of the hospital. This is the new story, five years in the making. It makes a difference to our patients. It makes a difference to their families. It makes a difference to our staff. So culture has changed. How to maintain momentum? It’s no secret—it’s hard, and there are setbacks. Bringing fresh new faces and ideas to the PICU Up! Task Force is invigorating. Some of the most passionate new PICU Up! champions were the most hesitant when the program started. But the most important ingredient is sharing multidisciplinary successes and valuing our work. Each member of the team brings invaluable perspective to the table. Sharing our experiences with colleagues from our own specialties is rewarding. Two examples: Our child life specialists recently presented a plenary session on their roles at the Association of Child Life Professionals meeting, and our nurses gave a keynote session at the National Teaching Institute and Critical Care Exposition. They are inspiring others to go back to their own units and effect change. As PICU mortality rates have fallen to all-time lows, it only makes sense that the pendulum is swinging in pediatric critical care to an emphasis on preventing morbidity and optimizing quality of life for our young patients.3,4 The SCCM PICU Liberation Collaborative is central to that mission, and the PICU Up! journey has provided just one example of how culture change is truly possible. Critical illness is a stressful time for children and their families. If we can give kids the best chance to be kids during a tough time, we’ve already made a huge difference. Referenes