Impacting Unit Culture through Interdisciplinary Collaboration

ACLP Bulletin | Summer 2017 | VOL. 35 NO. 3

Caroline Potter, CCLS
Emily Carlton, CCLS

In January of 2014, a nurse practitioner in the PICU at the Johns Hopkins Children’s Center noticed that acute rehabilitation was not prioritized in caring for critically ill children, and gathered an interdisciplinary group to address this need. Based on a strong foundation of data demonstrating benefits in adult patients, we set out to create a culture of mobility for pediatric patients and prove it makes a difference. The PICU Up! team was comprised of a nurse practitioner, a clinical nurse specialist, two child life specialists, an occupational therapist, two physical therapists, a respiratory therapist, and a physician. Together, we considered different ways to approach this goal. Our group was well aware that  mobilizing critically ill patients would have not only physiological effects, but would have a significant psychosocial impact. Early discussions focused on which patients should be included or excluded, what the barriers and facilitators would be, and what resources were available, to name a few. With each weekly meeting, many decisions were made, some were changed, and some thrown out, but a structured program began to take shape. Creating and implementing PICU Up! took over a year, and none of us could have predicted at the beginning where this project would take us. 

PICU Up! was an interdisciplinary endeavor from the beginning, and the role of each person as we went through the process of creating the program was fluid and ever-changing. In the earliest phases of brainstorming and thinking about how to create PICU UP!, our team developed in a way that gave every person a voice. In its infancy, it was a small enough group that it was possible for everyone to actively participate in discussions. Additionally, the means of accomplishing our goal was undefined enough that we really had to take the time to consider all perspectives and opinions. The tone set during these early meetings has been maintained and the dynamic of the group is truly positive and collaborative. Roles became more obvious for the implementation aspect of the program as it mostly entailed each discipline simply continuing their work but in a more coordinated way and with a larger scope. Team members had the opportunity to come back to each weekly meeting and share in real time what was and was not working with implementation, and the whole group would put their heads together to create possible solutions. 

Over time, the “core” group for PICU Up! has grown significantly, as an important aspect of our collaboration was expanding the scope of the program after initial implementation to continue to “push the envelope.”

Our PICU colleagues recognize that we are the experts on psychosocial needs and support, and we are identified as one of the first points of contact when mobilization of a patient is being considered. 

This second phase has included the addition of an assistive and augmentative communication program, expanding our levels to include ECMO patients, and optimizing sedation approaches and delirium prevention strategies to promote mobility. In addition, the collaborative nature of our team is highlighted by the fact that each involved discipline is encouraged to publish and present our work within our respective fields. The group now includes members of the ECMO perfusionist team, respiratory therapy, additional physician representation, additional nurse practitioners, palliative care, and more. Many of the medical team members have specialized interests that fall within the program including delirium, sleep, ECMO, safety and quality, and ICU survivorship. Perhaps even more impactful on our success as a team than the addition of staff is that the staff who have joined feel passionately about mobility and are actively pursuing collaboration and work with this group. The PICU Up! team now meets monthly to review active projects and discuss new ideas and next steps. As a team we have created a pediatric track at the annual Critical Care Rehabilitation Conference held at Johns Hopkins, which had a solely adult focus in the past, giving us the opportunity to educate PICU teams from around the world about creating a culture of mobility. 

The formal collaboration between disciplines stemming from PICU Up! has translated to a significant shift in the culture of our unit. However, it is the day-to-day operations of PICU Up! that have truly made the difference. On a daily basis, mobilizing patients in the PICU requires that bedside nurses, respiratory therapists, medical providers, physical and occupational therapists, and child life specialists work together with our patients and their families. No single member of the team could function separately from another.  Clear and timely communication with all stakeholders is necessary to set a patient up for a successful early mobility experience.  The coordination to move from bed to chair involves a certain level of involvement with other disciplines, as does walking outside the patient’s room, and certainly when trips off the unit are considered.  You cannot “keep it simple” by skipping steps and you cannot work in isolation.  Coordination and timely communication are crucial. When a team member identifies a patient for mobilization, we may have a team huddle with a provider, bedside nurse, respiratory therapist, rehab therapists, and child life specialists to discuss a systematic plan for moving and identify who is responsible for what equipment and what the process will be. Parents and the patient can contribute their perspectives to the plan, and any member of the team can ask questions or express concerns. It can be beneficial to continue to huddle prior to moving out of bed or ambulating so that as new people are involved, a clear plan is always agreed upon. An additional factor in shifting the unit culture was promoting our successes. With patient and parent consent, we took pictures and videos that we shared with staff so that those not present or directly involved could see the successful outcomes of our teamwork. This daily work and collaboration has been a significant factor in achieving a culture of mobility in our PICU.

Working with the PICU Up! project has created a truly unique opportunity for us as PICU child life specialists.  We are an integral part of helping critically ill children and adolescents experience an increased quality of life while in the intensive care unit, not only through environmental enhancements and other therapeutic interventions, but as active participants in their physical recovery. Our PICU colleagues recognize that we are the experts on psychosocial needs and support, and we are identified as one of the first points of contact when mobilization of a patient is being considered. Alongside the patients’ families, we determine how to best prepare children and adolescents for mobilizing. We continually assess and consider a patient’s mental status, taking into account the patient’s delirium screening, alertness, and ability to communicate with nonverbal cues or assistive communication devices, and we take seriously our job to advocate on their behalf during early mobility experiences. While we work with the entire medical team to create an environment where mobility can happen safely, we also aim to make it as enjoyable as possible. Due to decreased use of heavy sedation, the need for child life support has increased and the number of patients that are awake enough for us to work with directly has increased. By investing our time and expertise into an initiative that has changed our unit’s culture as profoundly as PICU Up!, we are able to impact patient’s experiences far beyond the hours we work. We have had the opportunity to present at pediatric grand rounds, and will present on several topics in collaboration with other team members for the Critical Care Rehabilitation Conference this year. The PICU Up! team, including child life, has participated in a collaborative with the Society for Critical Care Medicine to create a bundle to promote a culture of mobility that aims to become standard practice for PICUs across the country. Being a part of the PICU Up! initiative has given us the opportunity to share our experiences with our child life colleagues at other institutions as more PICUs begin their journeys into implementation of early mobilization. Our center’s experience confirmed that child life champions play a key role in acute rehabilitation efforts, and our success would not have been possible without fostering collaborative relationships.BulletinArticleBlueIcon