PICU Up! program aims to get kids moving earlier, recovering faster

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Instead of being heavily sedated for much of their stay in intensive care, patients are being encouraged to move as much as safely possible, improving their long-term recovery.


By Maureen Gilmer, IU Health senior journalist, mgilmer1@iuhealth.org

For months, the intensive care unit at Riley Hospital for Children had prepared for the launch of a new program designed to improve the mobility and recovery of patients.

Then the coronavirus hit.

They might have been forgiven if they decided to delay the launch of PICU Up!.

They did not.

On March 23, the PICU team, clad in their specially designed T-shirts, forged ahead.

PICU Associate Medical Director Dr. Danielle Maue is leading the charge.

“We’ve known in the adult world for a while that increased mobility earlier leads to better outcomes – decreased mortality, decrease in the number of ventilator days and a decrease in length of stay,” she said.

It seemed logical that the same would be true in pediatric patients, and now Dr. Maue and her team will be able to test that theory, with the results being included in a study by Johns Hopkins University researchers that also includes a few other children’s hospital units around the country.

“I’m in the ICU every day, and I see that we have traditionally sedated kids a lot, then they don’t move around a lot, they get weak, and it takes them a long time to get back to themselves,” Dr. Maue said.

When kids are really sick, that might be expected, but Dr. Maue believes there is enough evidence to support the idea that many patients can be mobilized safely.

“We are very good at having children survive their ICU stay. What I think we need to shift and focus on is not only surviving but having better outcomes.”

REDUCING DELIRIUM

She worked with a multidisciplinary team of nurses, respiratory therapists, physical therapists, occupational therapists, speech therapists and child life specialists to plan and implement the new strategy.

It was important to get buy-in from the staff, the team who would be working with the patients to safely get them moving.

Jake Copeland, a physical therapist who works with many of the kids on the unit, is excited about seeing the short- and long-term improvements in his patients.

“Studies show that 80% or more of PICU patients experience functional decline, and about a quarter of those who survive a PICU stay have not fully recovered all of their function six months after discharge,” he said. “PICU Up! can help us decrease the time our patients spend in the PICU in the first place, minimizing the amount of functional decline they experience while here.”

The culture in intensive care has traditionally been one of immobility, for obvious reasons. Patients are unstable by definition. By participating in the study, Riley’s PICU can begin to change that culture by raising awareness of the issues that medical treatment methods can create – namely delirium and slower recovery, Copeland said.

“It is quite difficult to effectively mobilize a child who is severely delirious after days or weeks of receiving sedating medications and having no semblance of a normal sleep/wake cycle, he explained.

But minimizing the use of sedation and creating an environment more conducive to normal sleep can lead to decreased instances of delirium and increased periods of mobility.

Occupational therapist Brittany McFarland agrees that the mobility program should help ease episodes of delirium, while also improving both the patient’s independence and the family’s involvement in their care.

“This program ensures that patients are set up for success,” she said. “If they are able to be alert and participatory, they are encouraged to be out of bed, or sitting up in bed, alert and engaging in their own care.”

FAMILIES CAN HELP

That means having self-care tasks such as hygiene routines done by specific times and maintaining as normal a schedule as possible. Families will feel more engaged and involved in their child’s care, patients will get stronger, and their ICU stays will be shorter, McFarland said.

“As therapists, we have always advocated for these things, but with PICU Up!, we are hoping entire patient care teams will be on the same page and have a hand in improving patient success,” she said.

The hope is that parents are onboard as well. Copeland said even if they are reluctant at first, they come around after an explanation of the benefits. Increased involvement on their part is a no-lose proposition.

“Intensive care is a setting in which families often feel disconnected from their child because they are scared and not taught or invited to help,” he said. “We want to give families more opportunities to engage and interact with their children because we think it will help us fight delirium and support our mobilization efforts.”

Before you get the wrong idea, not every patient is going to be walking around on a ventilator or on ECMO (extracorporeal membrane oxygenation), cautioned Dr. Maue.

“Our goal is to move these patients as much as we safely can, and if that means just shifting them in bed or sitting them up a little bit, that’s OK.”

Every morning on rounds, each patient gets assigned a level 1, 2 or 3, based on their illness, she said. The lower the number, the less movement. Patients with open chest or abdominal wounds and those with a do-not-resuscitate order are exempt from the program.

“There’s a lot going on right now,” Dr. Maue said, referring to COVID-19, “but people still wanted to push through and do this. I’m very proud of our unit for being willing to go forward with this under the circumstances.”

Dr. Maue, who completed her residency and fellowship within IU Health, is in her second year as an attending physician at Riley. She and her husband, Todd, have two young children, so they are navigating some of the same challenges other parents are during the self-isolation phase of battling the coronavirus.

“Like all of us, I’m trying to take things one day at a time and trying to control the things I can control. It has definitely been hard. My 6-year-old is in kindergarten and she knows that school is canceled because of the virus. She understands that it probably won’t make her sick but it could make some of her teachers sick, and that’s why we need to stay home and protect everyone.”

The mobility supplies for this program are supported by a $10,000 grant from Women for Riley, a philanthropic women’s group within Riley Children’s Foundation.

Photos by Mike Dickbernd, IU Health visual journalist, mdickbernd@iuhealth.org

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