Secondary Logo

Journal Logo

Institutional members access full text with Ovid®

Early Protocolized Versus Usual Care Rehabilitation for Pediatric Neurocritical Care Patients: A Randomized Controlled Trial

Fink, Ericka L. MD, MS1,2; Beers, Sue R. PhD3; Houtrow, Amy J. MD, MPH, PhD4; Richichi, Rudolph PhD5; Burns, Cheryl MS6; Doughty, Lesley MD7; Ortiz-Aguayo, Roberto MD, MMM8; Madurski, Catherine A. MD1; Valenta, Cynthia MSN, CNRN9; Chrisman, Maddie PT, DPT10; Golightly, Lynn MS, CCC-LP11; Kiger, Michelle MHS, OTR/L12; Patrick, Cheryl PT, MBA13; Treble-Barna, Amery PhD4; Pollon, Dorothy MBA, JD14; Smith, Craig M. MD15; Kochanek, Patrick MD, MCCM1,2; for the PICU-Rehabilitation Study Group

Pediatric Critical Care Medicine: June 2019 - Volume 20 - Issue 6 - p 540-550
doi: 10.1097/PCC.0000000000001881
Neurocritical Care
Buy
SDC

Objective s: Few feasibility, safety, and efficacy data exist regarding ICU-based rehabilitative services for children. We hypothesized that early protocolized assessment and therapy would be feasible and safe versus usual care in pediatric neurocritical care patients.

Design: Randomized controlled trial.

Setting: Three tertiary care PICUs in the United States.

Patients: Fifty-eight children between the ages of 3–17 years with new traumatic or nontraumatic brain insult and expected ICU admission greater than 48 hours.

Interventions: Early protocolized (consultation of physical therapy, occupational therapy, and speech and language therapy within 72 hr ICU admission, n = 26) or usual care (consultation per treating team, n = 32).

Measurements and Main Results: Primary outcomes were consultation timing, treatment type, and frequency of deferrals and safety events. Secondary outcomes included patient and family functional and quality of life outcomes at 6 months. Comparing early protocolized (n = 26) and usual care groups (n = 32), physical therapy was consulted during the hospital admission in 26 of 26 versus 28 of 32 subjects (p = 0.062) on day 2.4 ± 0.8 versus 7.7 ± 4.8 (p = 0.001); occupational therapy in 26 of 26 versus 23 of 32 (p = 0.003), on day 2.3 ± 0.6 versus 6.9 ± 4.8 (p = 0.001); and speech and language therapy in 26 of 26 versus 17 of 32 (p = 0.011) on day 2.3 ± 0.7 versus 13.0 ± 10.8 (p = 0.026). More children in the early protocolized group had consults and treatments occur in the ICU versus ward for all three services (all p < 0.001). Eleven sessions were discontinued early: nine during physical therapy and two during occupational therapy, none impacting patient outcome. There were no group differences in functional or quality of life outcomes.

Conclusions: A protocol for early personalized rehabilitation by physical therapy, occupational therapy, and speech and language therapy in pediatric neurocritical care patients could be safely implemented and led to more ICU-based treatment sessions, accelerating the temporal profile and changing composition of interventions versus usual care, but not altering the total dose of rehabilitation.

1Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA.

2Safar Center for Resuscitation Research, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.

3Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA.

4Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, PA.

5Statistical Analysis and Measurement Consultants Inc., Lanexa, VA.

6Department of Pediatrics, University of Pittsburgh Medical Center, Pittsburgh, PA.

7Division of Critical Care Medicine, Department of Psychiatry, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH.

8Department of Child and Adolescent Psychiatry and Behavioral Sciences, The Children’s Hospital of Philadelphia, Philadelphia, PA.

9Professional Practice and Education, Jefferson Hospital, Jefferson Hills, PA.

10Department of Physical Therapy, University of Pittsburgh Medical Center, Pittsburgh, PA.

11Audiology Communications Disorders, Department of Audiology and Speech-Language Pathology, UPMC Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA.

12Division of Occupational Therapy and Physical Therapy, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH.

13Departments of Occupational and Physical Therapy, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL.

14Special Needs Child Advocate and Study Stakeholder, Pittsburgh, PA.

15Division of Critical Care, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL.

Members of the PICU-Rehabilitation Study Group are listed in Appendix 1.

The views presented in this article are solely the responsibility of the author(s) and do not necessarily represent the views of Patient-Centered Outcomes Research Institute, its Board of Governors or Methodology Committee.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/pccmjournal).

Supported, in part, by Patient-Centered Outcomes Research Institute (PCORI) Award (CER-1310–08343) (to Dr. Fink), National Institutes of Health (K23 NS065132) (to Dr. Fink), National Institutes of Health (NIH) National Institute of Neurological Disorders and Stroke R01 NS096714 (to Dr. Fink), NIH (National Institute of Child Health and Human Development) U10HD049983 (to Dr. Fink).

Drs. Fink’s, Houtrow’s, Richichi’s, Ortiz-Aguayo’s, Smith’s, and Kochanek’s institutions received funding from Patient-Centered Outcomes Research Institute (PCORI). Dr. Richichi disclosed that he does statistical analysis for the University of Pittsburgh and disclosed work for hire. Dr. Kochanek received support for article research from PCORI. The remaining authors have disclosed that they do not have any potential conflicts of interest.

This project is registered with ClinicalTrials.gov (NCT02209935).

For information regarding this article, E-mail: finkel@ccm.upmc.edu

Copyright © 2019 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies