Thread by @PedsIntensiva

One podcast, two #rehablegend, season 3 episode 1 @PedsIntensiva

Early Mobilization feat. @SapnaKmd & Guest Editor @karen_choong

+ @drpetaalexander, @drgregkelly, Kate Thompson & Mike Clifford @rch

podcasts.apple.com/au/podcast/ear…

#ICUrehab #pedsICU @PICU_Up @mch_childrens

@SapnaKmd @karen_choong @drpetaalexander @drgregkelly @rch @PICU_Up @mch_childrens Can we stop children dying without giving them new problems?

Alongside gains in #pedsICU survival is parallel ⤴ in kids who leave w functional limitation– may affect life forever

Some related to illness but some related to what we do– or don’t do

#ICUrehab #rehablegend

@SapnaKmd @karen_choong @drpetaalexander @drgregkelly @rch @PICU_Up @mch_childrens #pedsICU has 2 distinct pops:

1.Kids who come in, get better & go. Teams, thoughts, training structured for these minority of bed days
2.Kids who stay > 1 wk – majority of bed days but systems ignore

#ICUrehab #rehablegend, pic @mch_childrens w parent consent

@SapnaKmd @karen_choong @drpetaalexander @drgregkelly @rch @PICU_Up @mch_childrens Sleep disturbance, delirium, delayed rehab. Don’t neglect moderate stay patients!

Long stay #pedsICU pts highest risk of functional impairment. In & out < 2 days probably less harm

BUT kids who are there for 3-4 days have problems & can't be ignored

#ICUrehab #rehablegend

@SapnaKmd @karen_choong @drpetaalexander @drgregkelly @rch @PICU_Up @mch_childrens First 24-48 hrs of #pedsICU is about resuscitation & stabilization, but #ICUrehab needs to start early

Unless you have systematic approach rehab gets forgotten until day 7-10 when there’s no acute issues left to discuss & it’s too late!..

#rehablegend

@SapnaKmd @karen_choong @drpetaalexander @drgregkelly @rch @PICU_Up @mch_childrens Studies show that globally we all have the same neglect of #ICUrehab! US, Canada, Europe, Brazil = same ☹

Functional impairment isn’t at the top of our minds when pts are admitted to #pedsICU

pubmed.ncbi.nlm.nih.gov/32168030/
https://t.co/MSMFetndgy
pubmed.ncbi.nlm.nih.gov/32576273/

#rehablegend

@SapnaKmd @karen_choong @drpetaalexander @drgregkelly @rch @PICU_Up @mch_childrens Many long stay #pedsICU pts have underlying chronic & complex comorbidities

Perception “less to gain” from #ICUrehab. While absolute decrement may be less, time to regain function greater

These pts have as much to gain as other patients!

#rehablegend

@SapnaKmd @karen_choong @drpetaalexander @drgregkelly @rch @PICU_Up @mch_childrens For babies, mobility is #therapeuticcuddles

i.e. being out of bed & held. #pedsICU has very young pts at most vulnerable stage of neurodevelopment. Have ⬇ baseline function so perception is don’t need mobilization - but do

pic @PICU_Up w parent consent #ICUrehab #rehablegend

@SapnaKmd @karen_choong @drpetaalexander @drgregkelly @rch @PICU_Up @mch_childrens Nothing that parents of #pedsICU pts want more than to hold their child

But after a few days of asking & being told no – parents just stop asking. It is on us as professionals to facilitate early mobility

#ICUrehab #rehablegend

@SapnaKmd @karen_choong @drpetaalexander @drgregkelly @rch @PICU_Up @mch_childrens Early mobility is NOT about walking intubated patients (even though it’s very cool it’s a tiny minority of the work)

It's about doing the most we can for EVERY kid, EVERY day, ensuring #illnessdoesntmeanstillness

#ICUrehab #rehablegend #pedsICU pic @PICU_Up w parent consent

@SapnaKmd @karen_choong @drpetaalexander @drgregkelly @rch @PICU_Up @mch_childrens We can do SOMETHING to enhance neuro & functional recovery for every #pedsICU pt, every day

Early mobility might just mean optimizing sleep/wake for paralysed HFOV pt – b/c that’s all you can do. BIG barrier to early mobility is PT/ OT turned away b/c “too sick today”

#ICUrehab

@SapnaKmd @karen_choong @drpetaalexander @drgregkelly @rch @PICU_Up @mch_childrens We are all taught “A-B-C” frameworks for hemodynamics in the #pedsICU – but not frameworks for #ICUrehab & early mobility...

..Such frameworks exist & are incredibly useful, e.g.

pubmed.ncbi.nlm.nih.gov/27759596/
pubmed.ncbi.nlm.nih.gov/31073462/

#rehablegend #illnessdoesntmeanstillness

@SapnaKmd @karen_choong @drpetaalexander @drgregkelly @rch @PICU_Up @mch_childrens “ABCDEFGH” #pedsICU rehab care bundle:

Attention to Analgesia; Avoid oversedation; allow Awake
Breathing trials
Choice of sedation & analgesia
Delirium prevention, surveillance, & mx
Early mobilization & Exercise
Family engage & empower
Good nutrition
Humanism

#ICUrehab

@SapnaKmd @karen_choong @drpetaalexander @drgregkelly @rch @PICU_Up @mch_childrens Early mobility brings MORE of your team to the table than any other project

Early mobility improves outcomes in your team AND in your patients ⬆interprofessional comms & psychological / emotional wellbeing of staff

pic @PICU_Up w parent consent
#ICUrehab #rehablegend #pedsICU

@SapnaKmd @karen_choong @drpetaalexander @drgregkelly @rch @PICU_Up @mch_childrens Share seamlessly & steal shamelessly!

Early mobility will look different in every place – because every place is different. Local adaptations, creations & implementation make it work & can / should be shared widely

#ICUrehab #rehablegend #pedsICU

@SapnaKmd @karen_choong @drpetaalexander @drgregkelly @rch @PICU_Up @mch_childrens Early mobility in the #pedsICU is clearly possible

Now it’s becoming imperative…

#ICUrehab #rehablegend

pic @mch_childrens w parent consent

@SapnaKmd @karen_choong @drpetaalexander @drgregkelly @rch @PICU_Up @mch_childrens If you want to shape & influence a field, concentrate on your “shaping strategy” - creation and free sharing of resources, frameworks, guidelines & support

Helped early mobility concepts to spread rapidly around the #pedsICU world

hbr.org/2008/10/shapin…

#ICUrehab #rehablegend

@SapnaKmd @karen_choong @drpetaalexander @drgregkelly @rch @PICU_Up @mch_childrens It’s all about culture change!

Implementation is the most challenging (& fascinating) part of research, especially with complex interventions like early mobility

#ICUrehab #rehablegend #pedsICU

@SapnaKmd @karen_choong @drpetaalexander @drgregkelly @rch @PICU_Up @mch_childrens Early mobility in the #pedsICU is fun, especially in the time of social media

Knowledge and ideas spread at light speed!

#ICUrehab #rehablegend

@SapnaKmd @karen_choong @drpetaalexander @drgregkelly @rch @PICU_Up @mch_childrens You DON'T need a background or formal quals in QI to start improving things at your place

There are lots of great frameworks out there, and people who can help. You’ll get better as you go (that’s what QI is, after all)

#ICUrehab #rehablegend #pedsICU

@SapnaKmd @karen_choong @drpetaalexander @drgregkelly @rch @PICU_Up @mch_childrens Artificial distinction btw “QI” & “research” not helpful, nor is downplaying importance of QI

QI might start at one center, but can be adapted – and published. LOTS of most exciting work in #pedsICU is "QI" - @PICU_Up, @pc4quality, @pediRESQ, @pac3quality

#ICUrehab #rehablegend

@SapnaKmd @karen_choong @drpetaalexander @drgregkelly @rch @PICU_Up @mch_childrens @pc4quality @pediRESQ @pac3quality Don’t ignore low-hanging fruit! Downside of #pedsICU social media is “cool” stuff (#ECMO walking) shared > "less exciting” stuff which is more common & important.

Less tweets of kid sitting on side of bed dangling legs

#ICUrehab #rehablegend pic @mch_childrens w parent consent

@SapnaKmd @karen_choong @drpetaalexander @drgregkelly @rch @PICU_Up @mch_childrens @pc4quality @pediRESQ @pac3quality Truth bomb: In early mobility – doing the small things early is what sets up patients to do more later!

…not letting pts getting weak & contracted in the first place

Lots of small things -> leads to being ready to get up & walk

#ICUrehab #rehablegend

@SapnaKmd @karen_choong @drpetaalexander @drgregkelly @rch @PICU_Up @mch_childrens @pc4quality @pediRESQ @pac3quality The key to early mobility working is that doctors get out of the way and bedside nurses & PT / OT start communicating directly about what the patient’s activity levels could be for the day

Doctors backing up / supervising > doctors driving

#ICUrehab #rehablegend #pedsICU

@SapnaKmd @karen_choong @drpetaalexander @drgregkelly @rch @PICU_Up @mch_childrens @pc4quality @pediRESQ @pac3quality Link to audio here:

podcasts.apple.com/au/podcast/ear…

#pedsrocks #ICUrehab #rehablegend

@SapnaKmd @karen_choong @drpetaalexander @drgregkelly @rch @PICU_Up @mch_childrens @pc4quality @pediRESQ @pac3quality Family is the number 1 predictor of early mobility

Family is the key to #ICUrehab

#rehablegend #pedsICU

@SapnaKmd @karen_choong @drpetaalexander @drgregkelly @rch @PICU_Up @mch_childrens @pc4quality @pediRESQ @pac3quality Mobility can be a starting point, rather than an end point

Don’t need to wait until sedation / delirium / analgesia etc are ‘perfect.’ Starting to mobilise is a great prompt to screen for & fix the other things

#ICUrehab #rehablegend #pedsICU

@SapnaKmd @karen_choong @drpetaalexander @drgregkelly @rch @PICU_Up @mch_childrens @pc4quality @pediRESQ @pac3quality Restraints in #pedsICU contribute to delirium & immobility

PARK-PICU studies showed that rates now ~ 15% when previously were up to 100% in sedated & ventilated

pubmed.ncbi.nlm.nih.gov/31073462/
pubmed.ncbi.nlm.nih.gov/33116069/

#ICUrehab #rehablegend

@SapnaKmd @karen_choong @drpetaalexander @drgregkelly @rch @PICU_Up @mch_childrens @pc4quality @pediRESQ @pac3quality Majority of #ICUrehab is delivered by bedside nurses & the family – once they are empowered, educated & working as a team with PT / OT & medical

Massive improvement in resource use. PT / OT reserved for specialist therapy, not just getting pts out of bed

#rehablegend #pedsICU

@SapnaKmd @karen_choong @drpetaalexander @drgregkelly @rch @PICU_Up @mch_childrens @pc4quality @pediRESQ @pac3quality Resources are always a concern in #pedsICU – how do we ensure early mobility is not just ‘another thing’ for bedside nurses to do, esp. when they feel most responsible for safety of their patient?

In fact #ICUrehab can massively empower nursing staff

#rehablegend

@SapnaKmd @karen_choong @drpetaalexander @drgregkelly @rch @PICU_Up @mch_childrens @pc4quality @pediRESQ @pac3quality You DON’T have to have a sedation protocol

You DO have to have a systematic, score-based approach to assessing sedation & setting sedation goals

#ICUrehab #rehablegend #pedsICU

@SapnaKmd @karen_choong @drpetaalexander @drgregkelly @rch @PICU_Up @mch_childrens @pc4quality @pediRESQ @pac3quality Intubated babies cry

Awake babies cry

If we wouldn't give an awake baby a benzo for crying we should be thoughtful about giving it to an intubated baby too…

#ICUrehab #rehablegend #pedsICU

@SapnaKmd @karen_choong @drpetaalexander @drgregkelly @rch @PICU_Up @mch_childrens @pc4quality @pediRESQ @pac3quality Culture change is tiring! Make sure there are new people, energy & ideas coming in all the time

Eventually early mobility develops a life of its own & helps overcome change champion fatigue

#ICUrehab #rehablegend #pedsICU

@SapnaKmd @karen_choong @drpetaalexander @drgregkelly @rch @PICU_Up @mch_childrens @pc4quality @pediRESQ @pac3quality Early mobility brings hope to caregivers & bedside staff

What was considered difficult becomes easy. What was considered high risk becomes everyday care.

How can we do this today?

#ICUrehab #rehablegend #pedsICU

@SapnaKmd @karen_choong @drpetaalexander @drgregkelly @rch @PICU_Up @mch_childrens @pc4quality @pediRESQ @pac3quality There is no contraindication to #ICUrehab & early mobility. There are patient & team factors to consider, but we can do something for every patient, every day

Even if it just passive motion or optimising sleep / wake cycles

#ICUrehab #rehablegend #pedsICU

@SapnaKmd @karen_choong @drpetaalexander @drgregkelly @rch @PICU_Up @mch_childrens @pc4quality @pediRESQ @pac3quality #pedsICU has a lot to learn from our adult #ICU colleagues

Likewise adult ICU has lot to learn from peds. Almost every single thing we w pt & family centered care is welcome in adult critical care (except more fun with kids!)

#ICUrehab #rehablegend pic @PICU_Up w parent consent

@SapnaKmd @karen_choong @drpetaalexander @drgregkelly @rch @PICU_Up @mch_childrens @pc4quality @pediRESQ @pac3quality #COVID19 has shown the world that CRITICAL ILLNESS SUCKS & that long term, patients have issues

Most of the problems are post critical illness, not specific to COVID

#ICUrehab #rehablegend #pedsICU

@SapnaKmd @karen_choong @drpetaalexander @drgregkelly @rch @PICU_Up @mch_childrens @pc4quality @pediRESQ @pac3quality It’s not enough to save patient’s lives anymore, it’s all about survivorship

It’s not good enough to dc from ICU or hospital, call it a day & ignore long term problems

Every day must think “what can I do to optimise this patient’s survivorship?”

#ICUrehab #rehablegend #pedsICU

@SapnaKmd @karen_choong @drpetaalexander @drgregkelly @rch @PICU_Up @mch_childrens @pc4quality @pediRESQ @pac3quality Common Q. about #ICUrehab – what equipment? Need fancy stuff like cycle ergometers and virtual reality?

Most important ‘equipment’ is nursing staff, PT / OT, rehab team & family

Most useful physical equipment: chairs, play mats, lifts (& know how to use)

#rehablegend #pedsICU

@SapnaKmd @karen_choong @drpetaalexander @drgregkelly @rch @PICU_Up @mch_childrens @pc4quality @pediRESQ @pac3quality As early mobility programs mature – find that patients do less in bed activities & mobilise out of bed as soon as they are awake & able

#ICUrehab #rehablegend #pedsICU

@SapnaKmd @karen_choong @drpetaalexander @drgregkelly @rch @PICU_Up @mch_childrens @pc4quality @pediRESQ @pac3quality Early mobility is an overall cost saver due to shorter LOS, less morbidity and FEWER staff injuries

Mechanism unclear but perhaps because patients are stronger & need less assistance & because staff move them more safely

#ICUrehab #rehablegend #pedsICU

@SapnaKmd @karen_choong @drpetaalexander @drgregkelly @rch @PICU_Up @mch_childrens @pc4quality @pediRESQ @pac3quality Early mobility is a low cost, cost saving intervention that can be done all around the world, including in low / middle income countries

Little plastic shopping cart = early mobility aid

#ICUrehab #rehablegend #pedsICU

@SapnaKmd @karen_choong @drpetaalexander @drgregkelly @rch @PICU_Up @mch_childrens @pc4quality @pediRESQ @pac3quality No lack of scoring going on in most #pedsICU – is lack of planning around scores

Frustrating for nurses to be doing CAP-D, RASS, etc that no one utilises. These are tools to help teams understand their pts & speak uniform language, NOT compliance measures

#ICUrehab #rehablegend

@SapnaKmd @karen_choong @drpetaalexander @drgregkelly @rch @PICU_Up @mch_childrens @pc4quality @pediRESQ @pac3quality Scores for sedation, delirium, etc DON’T mean ignoring the gut feeling of bedside nurses

All scores are doing is quantifying that gut feeling, & help us speak a common language & better target interventions

Adding value to nursing impression

#ICUrehab #rehablegend #pedsICU

Senior physicians can be the most recalcitrant with getting on board with culture change & systematic approaches to #ICUrehab

Time & work can transform dinosaurs into champions

#rehablegend #pedsICU

Hot tip: sobriety awards for reducing sedation in #pedsICU patients

#ICUrehab #rehablegend

@karen_choong & @SapnaKmd

The passion & creativity of international #pedsICU community keeps inspiring & driving, even in the face of change champion fatigue

Hearing from institutions having challenges is more inspiring than easy success

#pedsrocks #ICUrehab #rehablegend

Early mobility & #ICUrehab is not just another thing to do - it’s a fundamental shift in EVERYTHING we do in #pedsICU, & it’s happening fast

Get on board!

#rehablegend pic @PICU_Up w parent consent

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