P2D256: Let’s Get Moving: Barriers to Early Mobility in the Pediatric Intensive Care Unit

Purpose/Objectives: Early mobilization of critically ill pediatric patients has the potential to improve patient outcomes and is shown to be safe and effective. Following the initiation of a PICU early mobility guideline and standardized consultation of physical therapy and occupational therapy in the PICU, an increase in deferred therapy sessions per unit days from 14% to 28% occurred as indicated by a missed therapy note in patients’ charts. To address this problem, a PDSA-cycle was performed in order to:
1. Understand staff, family, and patient factors related to therapy deferrals.
2. Develop targeted interventions to prevent unnecessary deferrals of therapy.

Design/Methods: A retrospective chart review was conducted of 829 ICU-based missed therapy notes from occupational, physical, and speech therapy between April and May 2021. The reasons for therapy deferral were analyzed and categorized into six groups: not medically appropriate, scheduling conflicts, patient/parent refusal, patient sleeping, nursing concerns, and other/unknown. Following classification of reasons for deferrals, focus groups with key stakeholders, including physical therapists, occupational therapists, nurses, and physicians, reviewed the data and developed two interventions to decrease barriers to therapy. These interventions were implemented in August of 2021 and their impact on therapy deferrals was monitored for the following 6 months.

Results: The six categories of deferral reasons were identified iteratively during the analysis process. The most common categories of reason for deferral were classified as: “not medically appropriate” (34%), scheduling conflicts (27%), patient or parent refusal (12%), and patient sleeping (12%). The parties most commonly deferring therapy were: unknown (48%), nurse/physician (26%), patient/family (14%), and therapist (12%). Based on data reviewed and guidance from key stakeholders, two addressable barriers to reduce deferred therapy were identified as lack of family engagement and poor communication between nursing and therapy. To improve family engagement, educational materials were developed using family-centered language to explain the importance of therapy in recovery from critical illness and suggested roles for family members to participate in their child’s recovery process. In addition, a new process for nurse-therapist communication was implemented. After implementation of these interventions, deferred therapy sessions per unit days decreased from a median of 26% in the two months pre-intervention (April-May 2021), to 20% in the six months post-intervention (September 2021- February 2022).

Conclusion/Discussion: Implementation of a new PICU early mobility guideline and standardized consultation of physical therapy and occupational therapy lead to increased therapy deferrals due in part to modifiable barriers of poor communication and limited family engagement. Interventions focused on improved nurse-therapist communication and family engagement reduced therapy deferrals per unit days from 26% to 20%. Further efforts to improve compliance with early mobility guidelines will address other barriers to therapy.