Early Rehabilitation in Critically ill Children – the PICU Liber8 Study
Maternal, Child & Mental Health
Hospital-acquired complications (HACs) such as delirium, muscle weakness and sedative withdrawal are common in critically ill children admitted to Pediatric Intensive Care Unit (PICUs). These HACs result from excessive sedative use and prolonged bed-rest. HACs are important; they delay recovery and impact long-term physical, cognitive and emotional functioning in both patients and families. We developed an innovative rehabilitation bundle (“PICU Liber8”) to “liberate” children in from these complications and improve their recovery. Liber8 promotes a team approach to optimizing patient comfort, awakening from sedatives, early mobilization, and family engagement. We demonstrated that Liber8 could be safely and successfully implemented into routine practice in 2 PICUs in Ontario. Liber8 resulted in improved process of care, safety and quality of patient care, no increased nursing workload, and potential cost savings. This study provides important evidence on implementation, and is already being adopted in other PICUs across the globe.
ICU-based rehabilitation has been recommended as a standard of care for all critically ill patients to prevent delirium, sedative withdrawal, pressure injuries and muscle weakness, however, its adoption into routine practice is suboptimal globally. Practice guidelines are inadequate for practice change. Rehabilitation in the ICU-setting is challenging as it is complex and requires a change in culture from the traditional practices of excessive sedation, immobility and restricted family presence. Evidence on effective implementation is therefore crucial to translate rehabilitation into clinical practice. The objectives of the Liber8 study were to implement an early rehabilitation bundle in 2 Canadian PICUs, evaluate the factors that influence bundle adoption, and determine its impact on clinical practice and patient outcomes. We demonstrated that an early rehabilitation bundle can be successfully implemented and result in practice change and improved processes of care in a 24-month period. Liber8 improved the quality of care, reduced sedative use and time to mobilization, and reduced patient harm; the intervention was acceptable and family satisfaction improved. This study is innovative for the following reasons: 1) the intervention is a bundle of care that demonstrably changed traditional paradigms of practice; 2) it provides key generalizable evidence on how to implement rehabilitation into clinical practice in a collective and consistent manner in the PICU setting, and ensure it is applied to every patient, every day; and 3) it utilises implementation science methodology and analysis methods, and is the first PICU study to evaluate the costs and resources required to implement rehabilitation. We also have preliminary evidence on clinical and long-term post-ICU outcomes following rehabilitation. This study provides essential knowledge translation evidence to guide the implementation of early rehabilitation practices across ICUs. Furthermore, this evidence can be applied to the implementation of future complex interventions in the ICU. Now that we have demonstrated that rehabilitation can be reliably delivered unit-wide, the next steps are to perform a larger scale research to evaluate the impact of ICU-rehabilitation on short and longer-term functional and health related quality-of-life patient outcomes.
Early Rehabilitation in Critically ill Children: a two center Implementation Study. Choong K, Fraser D, Al-Farsi A, Awlad Thani S, Cameron S, Clark H et al. Pediatric Critical Care Medicine, In Press (PCCM-D-22-00666R2)