Barriers and facilitators of early mobilization at the pediatric intensive care unit: a systematic review

Daloia, Lígia Maria Tezo; Pinto, Ana Carolina Pereira Nunes; Silva, Élida Pereira da

doi:10.1590/1809-2950/20026728032021

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ORIGINAL RESEARCH • Fisioter. Pesqui. 28 (3) • Jul-Sep 2021 • https://doi.org/10.1590/1809-2950/20026728032021 copy

Barriers and facilitators of early mobilization at the pediatric intensive care unit: a systematic review

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

This systematic review aimed to identify barriers and facilitators for the implementation of early mobilization in pediatric intensive care units. A systematic search was carried out based on studies that addressed barriers and/or facilitators for early mobilization in children and adolescents. Studies published until June 2019 in the MEDLINE^®, Physiotherapy Evidence Database, Latin American & Caribbean Health Sciences Literature, Cochrane Library, and Scientific Electronic Library Online databases were included. Selection and assessment of methodological quality were performed by two independent reviewers. Data that could be identified as barriers and/or facilitators were extracted for analysis. 358 records were found in the databases, of which 13 articles were included. 18 barriers were cited; the most cited ones were the insufficient number of professionals and team’s insecurity. Of the 11 mentioned facilitators, the most frequent were training/education of the multidisciplinary team and the establishment of guidelines/consensus. There are many barriers to be broken for early mobilization to be effective, but some facilitators are already known and can be implemented, making their implementation feasible for the pediatric population.

Keywords:
Intensive Care Units; Pediatrics; Early Ambulation

Author/Year	Type of Study	Main Diagnoses	Details of the Study/Intervention	Barriers	Facilitators
Choong¹⁵15. Choong K, Awladthani S, Khawaji A, Clark H, Borhan A, Cheng J, et al. Early exercise in critically ill youth and children, a preliminary evaluation: the wEECYCLE pilot trial. Pediatr Crit Care Med. 2017;18(11):e546-54. doi: 10.1097/PCC.0000000000001329. https://doi.org/10.1097/PCC.000000000000... 2017**	RCT	Various diagnoses (mostly respiratory failure)	30 patients aged 3 to 17 years, with a stay of 48 hours or more in the PICU. The study compared conventional physical therapy versus conventional physical therapy associated with an upper limb cycle ergometer, 5x/week for 30 minutes a day.	Parent/patient refusal due to the patient's sleep schedule; generation of emotional stress and the possibility of causing pain to the patient; insufficient number of professionals.	Establishing an institutional practical guideline; involving other professionals and caregivers to perform EM.
Fink¹⁶16. Fink EL, Beers SR, Houtrow AJ, Richichi R, Burns C, Doughty L, et al. Early protocolized versus usual care rehabilitation for pediatric neurocritical care patients: a randomized controlled trial. Pediatr Crit Care Med. 2019;20(6):540-50. doi: 10.1097/PCC.0000000000001881. https://doi.org/10.1097/PCC.000000000000... 2019	RCT	Head trauma, cardiac arrest, stroke, brain mass, or central nervous system infection	58 children aged 3 to 17 years old, with a stay of 48 hours or more at the PICU. Performed EM versus usual care.	Patient out of room; request from nursing, parents, and/or patient; subjective complaint; unexpected visits from family members; abnormal intracranial pressure (instability).	Promoting improvement in team education, care delivery, and coordination; promoting practice based on personalized protocols.
Zheng¹⁷17. Zheng K, Sarti A, Boles S, Cameron S, Carlisi R, Clark H, et al. Impressions of early mobilization of critically ill children - clinician, patient, and family perspectives. Pediatr Crit Care Med. 2018;19(7):1. doi: 10.1097/PCC.0000000000001547. https://doi.org/10.1097/PCC.000000000000... 2018**	RCT	Various diagnoses (mostly respiratory failure)	A semi-structured interview was carried out with doctors, caregivers, family members ,and patients aged 8 years or over, who took part in a clinical trial of EM in critically ill children.	EM is not seen as a priority; concern for patient safety; insufficient number of physical therapists; lack of patient motivation.	Trust in the health team; belief in the importance of physical activity; engagement of the health team; engagement in research.
Choon¹⁸18. Choong K, Foster G, Fraser DD, Hutchison JS, Joffe AR, Jouvet PA, et al. Acute rehabilitation practices in critically ill children: a multicenter study. Pediatr Crit Care Med. 2014;15(6):1. doi: 10.1097/PCC.0000000000000160. https://doi.org/10.1097/PCC.000000000000... 2014	Retrospective cohort	Various diagnoses	600 patients aged 0 to 17 years old, with a stay of 24 hours or more at the PICU. Main outcome was to characterize the type of EM, time of onset, and eligible patients.	Parental and/or patient refusal; lack of medical prescription; need for a medical order not to perform the EM; patient's condition; insufficient staff; presence of a long-term catheter; insufficient equipment.	Physical therapist autonomy; elaboration of guidelines for practice.
Choong¹⁹19. Choong K, Chacon M, Walker R, Al-Harbi S, Clark H, Al-Mahr G, et al. In-Bed mobilization in critically ill children: a safety and feasibility trial. J Pediatr Intensive Care. 2015;4(4):225-234. doi: 10.1055/s-0035-1563545. https://doi.org/10.1055/s-0035-1563545... 2015	Retrospective cohort	Various diagnoses (mostly post-operative period)	25 patients, aged 3 to 17 years old, with a stay of more than or equal to 24 hours at the PICU. The study compared two methods (passive mobilization versus interactive video game), applied for a maximum of 2 days, lasting 20 minutes.	Improperly sized equipment; parent/patient refusal.	Educating the team; influencing a cultural change about EM; establishing EM protocols; encouraging research.
Abdulsatar²⁰20. Abdulsatar F, Walkera RG, Timmonsa BW, Choong K. "Wii-Hab" in critically ill children: a pilot trial. J Pediatr Rehabil Med. 2013;6(4):193-202. doi: 10.3233/PRM-130260. https://doi.org/10.3233/PRM-130260... 2013	Case series	Various diagnoses	8 patients divided into two groups, aged between 3 and 18 years old, with a stay of 48 hours or more at the PICU. The study used Nintendo Wii™ Boxing for at least 10 min, 2x/day for 2 days.	Lack of parental consent; refusal/lack of patient motivation; sedation; the non-specific game for rehabilitation; insufficient number of physical therapists.	Pleasant techniques for obtaining parental/patient approval; low cost of video game.
Betters⁴4. Betters KA, Hebbar KB, Farthing D, Griego B, Easley T, Turman H, et al. Development and implementation of an early mobility program for mechanically ventilated pediatric patients. J Crit Care. 2017;41:303-8. doi: 10.1016/j.jcrc.2017.08.004 https://doi.org/10.1016/j.jcrc.2017.08.0... 2017	Case series	Various diagnoses (mostly respiratory disease)	74 patients, aged 0 to 21 years, under MPV, with a hospital stay of 72 hours or more. Intervention lasting 30 minutes.	Deep sedation or neuromuscular block; delirium; work overload of physical therapists; culture of non-acceptance by the team for fear of adverse events; reduced number of physical therapists on weekends.	Physical therapist hired only to perform EM; multidisciplinary team training; pre-intervention safety checklist; protocol for EM.
Colwell²¹21. Colwell BRL, Williams CN, Kelly SP, Ibsen LM. Mobilization therapy in the pediatric intensive care unit: a multidisciplinary quality improvement initiative. Am J Crit Care. 2018;27(3):194-203. doi: 10.4037/ajcc2018193. https://doi.org/10.4037/ajcc2018193... 2018	Case series	Various diagnoses	The study implemented an EM protocol and evaluated the protocol's effectiveness for nine months, according to patient age and disease severity.	Patient instability; insufficient staff; parent/patient refusal; admission time; concern about the severity of the patient; concern about medical equipment.	Increasing the team's adherence to the EM protocol and promoting institutional education; understanding the family's perception of EM.
Cui²²22. Cui LR, LaPorte M, Civitello M, Stanger M, Orringer M, Casey F, et al. Physical and occupational therapy utilization in a pediatric intensive care unit. J Crit Care. 2017;40:15-20. doi: 10.1016/j.jcrc.2017.03.003. https://doi.org/10.1016/j.jcrc.2017.03.0... 2017	Case series	Various diagnoses	40 patients aged 14 days to 18 years old, with a stay of 72 hours or more at the PICU. The study characterized the patients, the physical therapy and OT sessions, and the adverse effects of EM, with each session lasting 20 minutes.	Patient's sleep schedule; prohibition by nursing staff; absence of a protocol for EM; delay to start mobilization; lack of clarity about EM risks and benefits; low prioritization of doctors for EM; interruption in sedation; parental prohibition; age.	Training of the multidisciplinary team and family members; showing family members the potential benefits of EM; contribution and collaboration of nursing.
Miura²³23. Miura S, Wieczorek B, Lenker H, Kudchadkar SR. Early Mobilization Task Force. Normal baseline function is associated with delayed rehabilitation in critically ill children. J Intensive Care Med. 2018;1-2. doi: 10.1177/0885066618754507. https://doi.org/10.1177/0885066618754507... 2018*	Case series	Various diagnoses	100 patients aged 1 to 17 years old. The study analyzed how many children received EM in the first 3 days of hospitalization and characterized the predictors for this.	Patient with normal baseline function; low severity score; physical therapist exclusivity and lack of professional; restricted knowledge about EM benefits.	Implementation of a EM program and optimization of EM culture at the PICU.
Parisien²⁴24. Parisien RB, Gillanders K, Hennessy EK, Herterich L, Saunders K, Lati J, et al. Experiences of four parents with physical therapy and early mobility of their children in a pediatric critical care unit: a case series. J Pediatr Rehabil Med. 2016;9(2):159-68. doi: 10.3233/PRM-160374. https://doi.org/10.3233/PRM-160374... 2016	Case series	Intubated and post-surgical patients	4 children under the age of 3 years old. An interview was conducted to explore the parents' experience.	Need for medical prescription; equipment unavailability; absence of practical guidelines; ineffective communication between health professionals and family members; inadequate staff training; insufficient number of professionals; concern with: orotracheal tube, risk of dislodgement of devices or catheters.	Family participation; awareness of the importance of EM and clarification of questions for family members; staff training; daily interruption of sedation; effective communication between health professionals; implementation of practical EM guidelines.
Tsuboi²⁵25. Tsuboi N, Nozaki H, Ishida Y, Kanazawa I, Inamoto M, Hayashi K, et al. Early mobilization after pediatric liver transplantation. J Pediatr Intensive Care. 2017;06(3):199-205. doi: 10.1055/s-0036-1593387. https://doi.org/10.1055/s-0036-1593387... 2017	Case series	After liver transplants	57 patients under 16 years old. The study evaluated the effectiveness of an EM protocol.	Absence of practical guidelines; lack of knowledge about the benefits of EM; need for medical prescription; conflicting perceptions regarding EM safety.	Adequate analgesia and sedation; training of the multidisciplinary team; team cultural transformation; setting goals for each patient daily; establishing an EM protocol.
Wieczorek²⁶26. Wieczorek B, Ascenzi J, Kim Y, Lenker H, Potter C, Shata NJ, et al. PICU Up!: Impact of a Quality Improvement Intervention to Promote Early Mobilization in Critically Ill Children. Pediatr Crit Care Med. 2016;17(12):e559-e566. doi: 10.1097/PCC.0000000000000983. https://doi.org/10.1097/PCC.000000000000... 2016*	Case series	Various diagnoses	100 patients aged 0 to 17 years old. EM performed in the first 72 hours at the PICU. The study assessed the results of implementing an EM program.	Procedure conduction; patient severity; bed rest orders; lack of specific equipment for the patient's age and size; need for medical prescription; insufficient staff.	Creation of a measure package for EM; staff training; discussion among professionals; safety assessment to perform EM.

Cochrane Risk-of-Bias Scale
Author/Year	Random sequence generation	Allocation concealment		Blinding of participants and professionals	Blinding of outcome evaluators	Incomplete outcome data	Selective outcome report		Other sources of bias
Fink⁵5. Fink E, Beers S, Houtrow A, Richichi R, Burns C, Doughty L, et al. Pilot RCT of early versus usual care rehabilitation in pediatric neurocritical care. Crit Care Med. 2018;46(1):394. doi: 10.1097/PCC.0000000000001881. https://doi.org/10.1097/PCC.000000000000... / 2019	+	+		+	+	+	+		+
Choong¹⁴14. Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA, editors. Cochrane handbook for systematic reviews of interventions [Internet]. Hoboken: Wiley; 2021 [cited 2021 Sep 27]. Available from: www.training.cochrane.org/handbook. www.training.cochrane.org/handbook... / 2017	+	+		-	-	+	+		+
Newcastle-Ottawa Scale for Cohort Studies
Author (year)	Selection				Comparability	Outcome			Score
	Representativeness of the exposed group	Selection of the unexposed group	Exposure verification	Demonstration that the outcome was not present at baseline	Based on design or analysis	Outcome assessment	Sufficient follow-up	Follow-up losses
Choong¹⁷17. Zheng K, Sarti A, Boles S, Cameron S, Carlisi R, Clark H, et al. Impressions of early mobilization of critically ill children - clinician, patient, and family perspectives. Pediatr Crit Care Med. 2018;19(7):1. doi: 10.1097/PCC.0000000000001547. https://doi.org/10.1097/PCC.000000000000... / 2014	+	+	+	-	+	+	+	+	7
Choong¹⁸18. Choong K, Foster G, Fraser DD, Hutchison JS, Joffe AR, Jouvet PA, et al. Acute rehabilitation practices in critically ill children: a multicenter study. Pediatr Crit Care Med. 2014;15(6):1. doi: 10.1097/PCC.0000000000000160. https://doi.org/10.1097/PCC.000000000000... / 2015	-	+	+	+	+	+	-	-	6
Newcastle-Ottawa Scale for Case Series
Author/Year	Selection				Outcome				Score
	Representativeness of cases	Proper case definition		Proper exclusion of other cases	All relevant data reported		Correct outcome assessment
Abdulsatar¹⁹19. Choong K, Chacon M, Walker R, Al-Harbi S, Clark H, Al-Mahr G, et al. In-Bed mobilization in critically ill children: a safety and feasibility trial. J Pediatr Intensive Care. 2015;4(4):225-234. doi: 10.1055/s-0035-1563545. https://doi.org/10.1055/s-0035-1563545... / 2013	+	+		+	+		+		5
Betters⁴4. Betters KA, Hebbar KB, Farthing D, Griego B, Easley T, Turman H, et al. Development and implementation of an early mobility program for mechanically ventilated pediatric patients. J Crit Care. 2017;41:303-8. doi: 10.1016/j.jcrc.2017.08.004 https://doi.org/10.1016/j.jcrc.2017.08.0... / 2017	-	+		+	-		+		3
Colwell²⁰20. Abdulsatar F, Walkera RG, Timmonsa BW, Choong K. "Wii-Hab" in critically ill children: a pilot trial. J Pediatr Rehabil Med. 2013;6(4):193-202. doi: 10.3233/PRM-130260. https://doi.org/10.3233/PRM-130260... / 2018	+	+		+	-		+		4
Cui²¹21. Colwell BRL, Williams CN, Kelly SP, Ibsen LM. Mobilization therapy in the pediatric intensive care unit: a multidisciplinary quality improvement initiative. Am J Crit Care. 2018;27(3):194-203. doi: 10.4037/ajcc2018193. https://doi.org/10.4037/ajcc2018193... / 2017	-	+		-	-		+		2
Parisien²³23. Miura S, Wieczorek B, Lenker H, Kudchadkar SR. Early Mobilization Task Force. Normal baseline function is associated with delayed rehabilitation in critically ill children. J Intensive Care Med. 2018;1-2. doi: 10.1177/0885066618754507. https://doi.org/10.1177/0885066618754507... / 2016	-	+		-	-		+		2
Tsuboi²⁴24. Parisien RB, Gillanders K, Hennessy EK, Herterich L, Saunders K, Lati J, et al. Experiences of four parents with physical therapy and early mobility of their children in a pediatric critical care unit: a case series. J Pediatr Rehabil Med. 2016;9(2):159-68. doi: 10.3233/PRM-160374. https://doi.org/10.3233/PRM-160374... / 2016	-	+		-	+		+		3
Wieczorek²⁵25. Tsuboi N, Nozaki H, Ishida Y, Kanazawa I, Inamoto M, Hayashi K, et al. Early mobilization after pediatric liver transplantation. J Pediatr Intensive Care. 2017;06(3):199-205. doi: 10.1055/s-0036-1593387. https://doi.org/10.1055/s-0036-1593387... / 2016	-	+		+	-		+		3

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