Authors' objectives: Early rehabilitation and mobilisation encompass patient-tailored interventions, delivered within intensive care, but there are few studies in children and young people within paediatric intensive care units. To explore how healthcare professionals currently practise early rehabilitation and mobilisation using qualitative and quantitative approaches; co-design the Paediatric Early Rehabilitation and Mobilisation during InTensive care manual of early rehabilitation and mobilisation interventions, with primary and secondary patient-centred outcomes; explore feasibility and acceptability of implementing the Paediatric Early Rehabilitation and Mobilisation during InTensive care manual within three paediatric intensive care units. Annually in the UK, 20,000 children (0–18 years) require life-sustaining treatment for critical illness and injury in paediatric intensive care units (PICU). As more than 96% of admissions to PICU survive, morbidity in survivors is now a major concern. The impact of being critically ill can manifest itself in weakness, cognitive impairment, organ dysfunction and psychological problems. Unfortunately, many children and young people (CYP) experience significant and residual physical, cognitive and psychosocial morbidities following PICU that impact on their quality of life (QoL). Our focus is to minimise iatrogenic harm of critical care and maximise patient outcomes through the development, testing and implementation of novel interventions.

Authors' results and conclusions: In the scoping review we identified 36 full-text reports evaluating rehabilitation initiated within 7 days of paediatric intensive care unit admission, outlining non-mobility and mobility early rehabilitation and mobilisation interventions from 24 to 72 hours and delivered twice daily. With the survey, 124/191 (65%) responded from 26/29 (90%) United Kingdom paediatric intensive care units; the majority considered early rehabilitation and mobilisation a priority. The observational study followed 169 patients from 15 units; prevalence of any early rehabilitation and mobilisation on day 3 was 95.3%. We then developed a manualised early rehabilitation and mobilisation intervention informed by current evidence, experience and theory. All three sites implemented the Paediatric Early Rehabilitation and Mobilisation during InTensive care manual successfully, recruited to target (30 patients recruited) and followed up the patients until day 30 or discharge; 21/30 parents consented to complete additional outcome measures. A randomised controlled trial is recommended to assess the effectiveness of the manualised early rehabilitation and mobilisation intervention. Phase 1a: scoping review We identified 36 articles that met the study eligibility criteria; 18 were full-text studies, mostly conducted in North America. There were only two RCTs; both were pilot studies confirming trial feasibility. Multicomponent ‘non-mobility’ and ‘mobility’ ERM interventions were feasible and safe. Most interventions involved physical therapy, occupational therapy and speech and language therapy. Children under 3 years old were more likely to receive ERM interventions such as cuddles or in-bed mobilisation, whereas non-ventilated children or those aged 3 years and older were more likely to receive mobility interventions involving physical or occupational therapy. Family involvement appeared crucial when considering non-mobility ERM for children under 3 years old. In 15/18 studies, judged to be of poor methodological quality, there was no benefit with regard to mechanical ventilation, hospital length of stay (LOS) and functional outcomes. Twelve of 18 studies provided some detail to aid replication and used qualified providers for supervision and tailored interventions. Although training and organisational strategies were sometimes applied, reporting was poor and complex intervention theories were rarely incorporated. A definitive trial of ERM in PICU appears feasible. ERM is a complex intervention requiring institutional, departmental and multidisciplinary involvement. We have demonstrated that implementation of the PERMIT manual is acceptable, feasible and can deliver ERM safely to critically unwell and injured infants and CYP within the PICU. Further research in a definitive trial with economic assessment and demonstration of improvement in patient-related outcomes is required.

Authors' methods: Mixed-methods feasibility with five interlinked studies (scoping review, survey, observational study, codesign workshops, feasibility study) in three phases. United Kingdom paediatric intensive care units. Children and young people aged 0–16 years remaining within paediatric intensive care on day 3, their parents/guardians and healthcare professionals. In Phase 3, unit-wide implementation of manualised early rehabilitation and mobilisation. Phase 1 observational study: prevalence of any early rehabilitation and mobilisation on day 3. Phase 3 feasibility study: acceptability of early rehabilitation and mobilisation intervention; adverse events; acceptability of study design; acceptability of outcome measures. Searched Excerpta Medica Database, Cumulative Index to Nursing and Allied Health Literature, MEDLINE, PEDro, Open grey and Cochrane CENTRAL databases. Narrative synthesis. The findings represent the views of National Health Service staff but may not be generalisable. We were unable to conduct workshops and interviews with children, young people and parents to support the Paediatric Early Rehabilitation and Mobilisation during InTensive care manual development due to pandemic restrictions. A mixed-methods study with three phases and five interlinked studies. Phase 1a: scoping review of literature Studies [randomised controlled trials (RCTs) and observational studies] of CYP (≤18 years), admitted to PICU, receiving early (within 7 days) rehabilitation and mobilisation and measuring an outcome (participants’ health and well-being, health service utilisation, feasibility, acceptability or intervention implementation) were identified in electronic bibliographic databases from inception to November 2021. Study selection, data extraction and risk of bias assessment [using the Cochrane RoB tool; Risk of Bias in Non-randomised Studies – of Interventions (ROBINS-I)] were undertaken by reviewers independently. Findings were narratively synthesised.

Project Status: Completed

URL for project: https://www.journalslibrary.nihr.ac.uk/programmes/hta/17/21/06

Year Published: 2023

URL for published report: https://www.journalslibrary.nihr.ac.uk/hta/HYRW5688

URL for additional information: English

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: England, United Kingdom

DOI: 10.3310/HYRW5688

Organisation Name: NIHR Health Technology Assessment programme

Contact Address: NIHR Journals Library, National Institute for Health and Care Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK

Contact Name: journals.library@nihr.ac.uk

Contact Email: journals.library@nihr.ac.uk