Discordance between early mobility protocol expectations and nurse-led mobilizations of critically ill children: A quality improvement initiative

Table 1 Baseline demographics and clinical characteristics, n (%)

Characteristic
Age
< 2 years	27 (30.7)
3-5 years	12 (13.6)
6-12 years	30 (34.1)
13-18 years	19 (21.6)
Gender
Male	59 (58.4)
Female	42 (41.6)
PICU day (median, IQR)	5 (4-6)
Reason for PICU admission
Surgical	14 (13.9)
Medical	77 (76.2)
Trauma or other	10 (9.9)
PRISM score
Low risk (0-10)	89 (88.1)
Moderate risk or greater (11-30+)	12 (11.9)
Preadmission PCPC score
Good	50 (49.5)
Mild disability	15 (14.9)
Moderate disability	13 (12.9)
Severe disability/coma or vegetative state	23 (22.8)
Respiratory support category
No support or cannula/mask	54 (53.5)
NIPPV/tracheostomy collar	12 (11.9)
Invasive mechanical ventilation	35 (34.7)
Equipment
Airway equipment (endotracheal tube/tracheostomy)	36 (35.6)
Lines (arterial line or central venous line)	54 (53.5)
Drains and catheters	28 (27.7)
Tubes (gastric/nasogastric tube)	67 (66.3)
Any sedation > 30 minutes	35 (34.7)
Any vasoactive within 24 hours	10 (9.9)

PICU: Pediatric intensive care unit; IQR: Interquartile range; PRISM: Pediatric Risk of Mortality Score; PCPC: Pediatric cerebral performance category; NIPPV: Non-invasive positive pressure ventilation.

Table 2 Mobilization data as reported by electronic health record, nurse report, and expected values, n (%)

PICU Up! level	EHR1	RN-report2	Expected
Level 1	13 (12.9)	9 (8.9)	24 (23.8)
Level 2	26 (25.7)	13 (12.9)	23 (22.8)
Level 3	48 (47.5)	51 (50.5)	54 (53.5)
Undocumented/unknown	14 (13.9)	28 (27.7)	0 (0)
Highest level of mobility achieved	EHR3	RN-report4
Bedrest or passive movement	54 (53.5)	34 (33.7)	28 (27.7)
In-bed activities	8 (7.9)	14 (13.9)	19 (18.8)
Out-of-bed activities	14 (13.9)	31 (30.7)	24 (23.8)
Standing or ambulating	25 (24.8)	22 (21.8)	30 (29.7)
Number of nurse-led mobilizations per shift (median, IQR)	1 (2)	6 (2)	6 (0)
Potential safety event rate per mobilization	0.02 (2/101)	0.02 (12/606)	0 (0)

¹Agreement in PICU Up! level between electronic health record and expected - 56.4%; κ = 0.34.

²Agreement in PICU Up! level between registered nurse report and expected - 53.5%; κ = 0.32.

³Agreement in highest level of mobility between electronic health record and expected - 39.6%: κ = 0.17.

⁴Agreement in highest level of mobility between registered nurse report and expected - 40.6%: κ = 0.20.

PICU: Pediatric intensive care unit; EHR: Electronic health record; RN-report: Registered nurse report; IQR: Interquartile range.

Table 3 Univariate predictors of discordance between nurse-reported and expected mobility

Characteristics	Discordance in PICU Up! level between expected and RN-report		Discordance in HLM between expected and RN-report
	OR	95%CI	OR	95%CI
Age (vs 0-2 years)
3-5 years	0.91	0.24, 3.43	0.81	0.22, 3.01
6-12 years	1.09	0.39, 3.04	0.71	0.25, 1.98
13-18 years	0.74	0.23, 2.40	2.13	0.62, 7.29
Gender (vs male)
Female	0.78	0.33, 1.72	0.72	0.33, 1.60
PICU day	0.73	0.52, 1.03	0.86	0.62, 1.20
ICU reason (vs surgical)
Medical	0.79	0.26, 2.40	0.81	0.26, 2.54
Trauma or other	1.44	0.30, 6.95	0.84	0.17, 4.13
PRISM score (vs low risk)
≥ Moderate risk	1.67	0.51, 5.40	0.46	0.14, 1.48
PCPC score (versus normal)
Mild disability	1.31	0.41, 4.15	2.36	0.69, 8.01
Moderate disability	1.24	0.37, 4.19	0.80	0.25, 2.62
Severe disability	8.29a	2.56, 26.91	2.49	0.87, 7.15
Respiratory support (vs none or nasal cannula)
NIPPV or trach collar	1.06	0.31, 3.60	2.13	0.48, 9.43
Mechanical ventilation	1.91	0.82, 4.47	0.34b	0.14, 0.82
Equipment
Lines	1.34	0.62, 2.92	0.43b	0.19, 0.97
Drains and catheters	0.68	0.28, 1.62	0.59	0.25, 1.41
Gastric/nasogastric tube	1.97	0.85, 4.55	1.48	0.65, 3.39
No medical equipment	0.57	0.17, 1.91	0.31	0.093, 1.06
Any sedation > 30 minutes	0.95	0.42, 2.15	0.30b	0.13, 0.69
Any vasoactive within 24 hours	1.16	0.33, 4.07	0.66	0.19, 2.30
Delirium within 24 hours	3.24	0.46, 22.95	0.22	0.042, 2.09

^aP < 0.01.

^bP < 0.05.

PICU: Pediatric intensive care unit; HLM: Highest level of mobility achieved; ICU: Intensive care unit; PRISM: Pediatric Risk of Mortality Score; PCPC: Pediatric cerebral performance category; NIPPV: Non-invasive positive pressure ventilation.